Health declaration
*
Mandatory fields
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English
Personal identity number (12 digits)
*
First name
*
Last name
*
Address
Zip
City
E-mail
Mobile phone
*
Weight, children only (kg)
Destination
Departure date
Trip length
Trip purpose
Previously reacted adversely to vaccines
Description
Fever/ongoing infection
What?
Hypersensitivity/allergy
What?
Which?
Regular medication
What?
Chronic disease
What?
Ongoing treatment
Which?
Anticoagulant medicines
Which?
Depression/mental illness
Which?
Pregnant/planning pregnancy/breast-feeding
Month?
I approve that Svea Vaccin sends me information about vaccines by email.
I have read and agree with Svea Vaccine's
Privacy Policy for customer information
.
*
