Traveller's Medical Pack
UNIVERSITY HEALTH SERVICE TRAVELLER'S MEDICAL PACK REQUEST FORM
- First, read the information on the Traveller's
Medical Pack.
- Print and fill in the form
- Hand into University Health Service Medical Reception
or send by Fax at 2548 1430
- Collect Traveller's Medical Pack at the dispensary after
24 hours
- Please pay and show Student / I.D. Card at collection
- If you have already had an appointment with your doctor,
there is no need to fill in this form. Please obtain your prescription directly
from your doctor.
Remember:
Read "Advice to Travellers".
If you are pregnant or if you require vaccination / Malaria
prevention, you should consult your doctor at least one month prior
to departure.
Please note: Do you or your family members have any history of drug allergy?
*Yes/No. If yes, please specify _____________________.
PLEASE READ CAREFULLY THE INFORMATION SUPPLIED WITH YOUR MEDICINE.
| Rx | Date: _________________ |
NAME: (PRINT) ___________________________________________
STUDENT/STAFF NO.: ______________________________________
SEX: *M / F
AGE: _______
| Please supply: |
* one / two Adult's ($20 each) | |
| * one / two Child's ($25 each) | Traveller's Medical Pack(s) |
Signature of Applicant
For official use only
Physician's Signature
|
_________________
Please pay and show Student/I.D. Card
*Circle the appropriate
|