Name: Date of birth Male Female □ □ Email: Telephone number: Mobile number: PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW Total length of trip: Date of departure: COUNTRY TO BE VISITED CITY OR RURAL LENGTH OF STAY EXACT LOCATION OR REGION 1. 2. 3. Have you taken out travel insurance for this trip? Do you plan to travel abroad again in the future? TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT Holiday Staying in hotel Backpacking Additional information □ □ □ □ Business trip □ Cruise ship trip □ Camping/hostels □ Expatriate □ Safari □ Adventure □ Volunteer work □ Pilgrimage □ Diving □ Healthcare worker □ Medical tourism □ Visiting friends/family Women only Are you pregnant? Are you breast feeding? Are you planning pregnancy while away? Have you undergone FGM / been cut / circumcised Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
Name: Date of birth Male □ Female □ Email: Telephone number: Mobile number: PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW Date of departure: Total length of trip: COUNTRY TO BE VISITED EXACT LOCATION OR REGION CITY OR RURAL LENGTH OF STAY 1. 2. 3. Have you taken out travel insurance for this trip? Do you plan to travel abroad again in the future? TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT □ Holiday □ Staying in hotel □ Backpacking Additional information □ Business trip □ Cruise ship trip □ Camping/hostels □ Expatriate □ Safari □ Adventure □ Volunteer work □ Pilgrimage □ Diving □ Healthcare worker □ Medical tourism □ Visiting friends/family Women only Are you pregnant? Are you breast feeding? Are you planning pregnancy while away? Have you undergone FGM / been cut / circumcised Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?