Vaccination History Request

Complete the form below to request a copy of your vaccination history. You will need this for attending a travel clinic prior to foreign travel and sometimes for visiting certain countries, or if you move abroad.

Patient Details

Full Name *

Date of Birth *

Address *

Postcode *

I would like to request a copy of my vaccination history since *

Birth

Date (please specify):

I acknowledge that the request will be dealt with within working hours, Monday to Friday. It will be up to 5 working days to process the request and a paper copy will be ready to collect from reception during opening hours. A separate request must be completed for each family member *

I agree with the above statement

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 07 June 2024
Page created: 08 October 2026

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Vaccination History Request

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