Make an Appointment

First Name: *
Last Name: *
Date Of Birth (dd/mm/yyy): *
Email Address: *
Phone Number: *
Select your TMA Member Location?
Have You Been To This Location Before?	Yes No
If yes, approx what year?
Preferred Appointment:	Monday Tuesday Wednesday Thursday Friday Saturday Morning Afternoon After Hours
Destination/s:
Departure Date (dd/mm/yyy):
Trip Duration:
Style Of Travel:
Purpose Of Travel:
If travelling for work, do you require any particular forms or paperwork to be completed as a result of your visit?	Yes No
Number Of Persons For Appointment:
Names Of Extra Persons:
Dates Of Birth (dd/mm/yyy):
Anyone under 12 yrs coming to the appt?	Yes No
How did you find out about the Travel Medicine Alliance?
Comments:

“
Travel is more than the seeing of sights; it is a change that goes on, deep and permanent in the ideas of living.
- Miriam Beard b. 1901”

“
A good traveller has no fixed plans and is not intent on arriving.
- Lao Tzu ( 570-490 BC)”

Travel Health Information

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