Travel Consultation If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required To ensure the best possible service with our experience staff, please complete and submit the form below. When you receive our confirmation email, then phone us on (03) 366 3391 to book your appointment time. Full Name * Date of Birth * Nationality * Postal Address * Contact Phone Number * Email Address Usual Doctor Dr Shelley Louw Dr Joseph Pearson Dr Joanna Thwaites Dr Karin Lamb Dr Sarah Fountain Date of Departure * Date of Return * Countries Visited Please be specific about length in each place. * Reason for travel Holiday Business Work Accommodation Hotel Backpacker Safari Cruise Other Activities Sightseeing Independently Escorted Tour High Altitude Trekking Jungle Safari Sport Allergies * Please bring with you to your travel appointment: Itinerary Travel immunisation record (if available)