Retail Archives | Nomad Health

How many people are traveling?*

If more than one person is travelling you need to use the blue tabs in the Trip Information section below to complete a form for each traveller.

How many people need a prescription?*

I need a Letter of Authority

I would like a cover letter signed by the prescriber detailing the medicines provided for use on my trip. I understand there is an additional charge of £15

Trip Information

Which countries are you travelling to?*

Date of departure*

Date of return*

First Traveller's Information

Name (as it appears on your passport)*

First Last

Address*

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone*

Email*

Name of your GP*

Your GP surgery name*

Your GP surgery postcode*

Would you like us to inform your doctor of any medicines we have provided you?

Yes
No

Your Date of Birth*

Your Weight (kg)*

Your Sex*

Female
Male

Are you pregnant or trying to become pregnant?*

Yes
No

Are you currently breastfeeding?*

Yes
No

Are you suffering from any ongoing medical conditions?*

Yes
No

Please provide details of your medical condition(s), answering as thoroughly as possible*

Do you take any regular medication?*

Yes
No

Please list the medications you take, separated by commas*

Do you have any known allergies?*

Yes
No

Please list your known allergens, separated by commas*

Second Traveller's Information

Second Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Third Traveller's Information

Third Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Fourth Traveller's Information

Fourth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Fifth Traveller's Information

Fifth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Sixth Traveller's Information

Sixth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Seventh Traveller's Information

Seventh Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery name (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Eighth Traveller's Information

Eighth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Your GP surgery name (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Ninth Traveller's Information

Ninth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Your GP surgery name (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Tenth Traveller's Information

Tenth Traveller's Name (as it appears on their passport)*

First Last

Address (if different from first traveller)

Building Name/Number Address Town/City County Postcode

Please note: we require a UK address in order to dispatch your order for this medication

Phone (if different from first traveller)

Email (if different from first traveller)

Your GP surgery name (if different from first traveller)

Name of your GP (if different from first traveller)

Your GP surgery postcode (if different from first traveller)

Their Date of Birth*

Their Weight (kg)*

Their Sex*

Female
Male

Are they pregnant or trying to become pregnant?*

Yes
No

Are they currently breastfeeding?*

Yes
No

Are they suffering from any ongoing medical conditions?*

Yes
No

Please provide details of their medical condition(s), answering as thoroughly as possible*

Do they take any regular medication?*

Yes
No

Please list the medications they take, separated by commas*

Do they have any known allergies?*

Yes
No

Please list their known allergens, separated by commas*

Retail

Trip Information

First Traveller's Information

Second Traveller's Information

Third Traveller's Information

Fourth Traveller's Information

Fifth Traveller's Information

Sixth Traveller's Information

Seventh Traveller's Information

Eighth Traveller's Information

Ninth Traveller's Information

Tenth Traveller's Information

Prescription Consultation 2022

Trip Information

First Traveller's Information

Second Traveller's Information

Third Traveller's Information

Fourth Traveller's Information

Fifth Traveller's Information

Sixth Traveller's Information

Seventh Traveller's Information

Eighth Traveller's Information

Ninth Traveller's Information

Tenth Traveller's Information

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IMPORTANT INFORMATION

Prescription Consultation 2022

Trip Information

First Traveller's Information

Second Traveller's Information

Third Traveller's Information

Fourth Traveller's Information

Fifth Traveller's Information

Sixth Traveller's Information

Seventh Traveller's Information

Eighth Traveller's Information

Ninth Traveller's Information

Tenth Traveller's Information

Prescription Consultation 2022

Trip Information

First Traveller's Information

Second Traveller's Information

Third Traveller's Information

Fourth Traveller's Information

Fifth Traveller's Information

Sixth Traveller's Information

Seventh Traveller's Information

Eighth Traveller's Information

Ninth Traveller's Information

Tenth Traveller's Information

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