Traveling
abroad?

Need advise or vaccinations for your next trip? Fill out the form below.
Travel form
Travelling requires planning, especially when you use medication or travel to other continents. Sometimes you need to declare your medication by showing customs a list of the medication you are using. The list can be obtained from your pharmacy or by printing a list which you can find in your 'uwzorgonline'-app. We can sign this list if needed.

Information about medication abroad? See link .
Need assistance at the airport? You don't need anything from your doctor, see link .
Fill out the form below to ask for travel and vaccination advise
Invuldatum
Geboortedatum
Geslacht
TRAVEL DETAILS
Date of departure
VACCINATION DETAILS
Have you been vaccinated before?
Have you had any problems after the vaccination?
Do you have a (yellow) vaccination booklet?
Have you taken malaria pills before?
MEDICAL DATA
Are you taking the birth-control pill?
Are you pregnant?
Are you breastfeeding?
Do you have any allergy?
Bedankt voor het invullen van het formulier.

We nemen contact met u op, als u binnen 3 dagen niets hoort, neem dan zelf contact op.
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