Secure Questionnaire | Quinte Travel Health Clinic

TRAVEL ITINERARY & IMMUNIZATION HISTORY

We adhere to the Personal Information Protection Act to protect your privacy


Accessibility Services are available at our location. If required, please contact our office in advance of your appointment for directions to the elevator / office access or CLICK HERE for full details.

PLEASE COMPLETE ONE QUESTIONNAIRE FOR EACH PERSON ATTENDING

 

 
Would you like to book your appointment in Kingston or Belleville?        
A

days      

 
1
2
3
4

B

Purpose of trip






Where will you be staying?





Possible activities









C

IMMUNIZATION HISTORY
Vaccine Date of Last Dose Vaccine Date of Last Dose
   
   
   
   

D

 

 

 

18/11/2018 (d/m/y)

Note: Most vaccines are generally well tolerated; however, you may experience some soreness, redness and swelling at the injection site. Other adverse reactions may include headaches, fever, fatigue, and muscle pa in. As with any vaccine, an allergic reaction or anaphylactic response could occur.