Travel Clinic

Personal details
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Medical Details

Applicant Declaration, Confidentiality Agreement and Personal Data Statement

I confirm that all the information I have given is correct. Where applicable I have no reason to think that I am pregnant. Where vaccinations are given, I hereby give my consent. In respect of children under 16, I give my consent as their parent/legal guardian. The information collected on this form will be held in accordance with the Data Protection (Jersey) Law 2018 and will be used by Island Medical Centre Partnership (hereafter the ‘Practice’) for the purposes of travel healthcare and related services and administration. I am aware that personal data relating to myself, whether obtained from myself or from any other source, will be retained by the Practice for the purposes of providing me with travel healthcare and related services both inside and outside of the Practice. I acknowledge that this may require my personal data to be forwarded to other persons for the purpose of referrals and for other lawful purposes related to the Practice procedures. I hereby consent to the holding and disclosure of my personal data by the Practice for the purposes and in the manner set out above and accept that the Practice will not be liable for any subsequent release of my details to any unauthorised third party through any method beyond its control. I understand that the Practice has the right to accept or decline this application. I agree to pay all travel vaccination treatment given by the Practice at the time of treatment.

To book an appointment call 01534 51 61 51