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    {"id":542,"date":"2026-08-22T11:52:39","date_gmt":"2026-08-22T10:52:39","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/m91021\/?page_id=542"},"modified":"2026-08-22T11:53:03","modified_gmt":"2026-08-22T10:53:03","slug":"travel-health","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/m91021\/travel-health\/","title":{"rendered":"Travel Health"},"content":{"rendered":"<p>If you require any vaccinations relating to foreign travel you need to make an appointment with the practice nurse to discuss your travel arrangements. This will include which countries and areas within countries that you are visiting to determine what vaccinations are required. We will ask you to complete a travel vaccination form and book a telephone triage appointment with our Practice Nurse to discuss requirements. A further face to face appointment will be required if the Practice Nurse needs to administer any vaccinations<\/p>\n<p><strong>Please note; Lockstown Practice is no longer a registered Yellow Fever Centre.\u00a0If you need to search for a Yellow Fever centre near you please follow the link to the national website.<\/strong><\/p>\n<p><strong>Further information can be found on the\u00a0<a href=\"https:\/\/nathnacyfzone.org.uk\/\">https:\/\/nathnacyfzone.org.uk<\/a><\/strong><\/p>\n<h3>Further Travel Information<\/h3>\n<p>The following websites will give you additional travel advice<\/p>\n<p><a href=\"https:\/\/www.nhs.uk\/conditions\/travel-vaccinations\/jabs\/\" target=\"_blank\" rel=\"noopener noreferrer\">Travel Health<\/a> for information of vaccinations available on NHS<\/p>\n<p><a href=\"https:\/\/www.masta-travel-health.com\/\" target=\"_blank\" rel=\"noopener noreferrer\">MASTA<\/a> for private vaccination clinics<\/p>\n<p><a href=\"https:\/\/www.gov.uk\/foreign-travel-advice\" target=\"_blank\" rel=\"noopener noreferrer\">Gov.uk<\/a> for specific country travel advice<\/p>\n<p><a href=\"https:\/\/www.nhs.uk\/NHSEngland\/Healthcareabroad\/EHIC\/Pages\/about-the-ehic.aspx\" target=\"_blank\" rel=\"noopener noreferrer\">EHIC <\/a>to apply for your free European Health Insurance Card<\/p>\n<details class=\"nhsuk-details nhsuk-expander\">\n\t\t\t<summary class=\"nhsuk-details__summary\">\n\t\t\t\t<span class=\"nhsuk-details__summary-text\">Travel Vaccination Prices<\/span>\n\t\t\t<\/summary>\n\t\t\t<div class=\"nhsuk-details__text\"><\/p>\n<p>Travel advice is covered by the NHS; however some vaccinations and prescriptions are only available privately. Payment for non-NHS services must be made at the first travel appointment.<\/p>\n<p>The following vaccines are immediately available in the surgery:<\/p>\n<p>NHS: Diphtheria, Tetanus, Polio, Hepatitis A, Typhoid<\/p>\n<p>Non-NHS: Hepatitis B (adult) \u00a325 per dose (usually 3 or 4 required), Rabies \u00a355 per dose (usually 3 required)<\/p>\n<p>The following vaccines can be obtained by private prescription and a charge of \u00a325 is payable to the surgery for each visit to administer. The cost of the vaccine is also payable to the chemist. You will be required to obtain the necessary vaccines and pay the pharmacy separately for these and return them to the practice for administration.<\/p>\n<p>Hepatitis B (child) Meningitis ACWY, Japanese Encephalitis, Tick-borne Encephalitis.<\/p>\n<p><strong>Vaccines must be stored between 2 and 8 degrees in a refrigerator<\/strong>; the ideal way to do this is to hand them in to the practice as soon as possible.<\/p>\n<p>All anti-malaria medications are provided privately. If recommended a private prescription will be issued at a cost of \u00a315 and the cost of the medication will be payable to the pharmacy.<\/p>\n<p>Yellow Fever vaccination is not provided in the surgery but available from specialist travel clinics.<\/p>\n<p><\/div>\n\t\t<\/details>\n<hr \/>\n<h3>Travel Assessment<\/h3>\n<p>If you are travelling abroad please complete and submit the travel form in plenty of time (we recommend 6-8 weeks) before your journey.<\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_18' ><div id='gf_18' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_18' id='gform_18'  action='\/m91021\/wp-json\/wp\/v2\/pages\/542#gf_18' data-formid='18' novalidate>\n        <div id='gf_progressbar_wrapper_18' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_18_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_18' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_18_3\" class=\"gfield nhsuk-form-group gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' ><span class='gform-field-label__text'>Name<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_3'>\n                            \n                            <span id='input_18_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.3' id='input_18_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_3.6' id='input_18_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_18_4\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Date of Birth<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_18_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_18_4_2_container'><label for='input_18_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_18_4_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_18_4_1_container'><label for='input_18_4_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_18_4_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_18_4_3_container'><label for='input_18_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_4[]' id='input_18_4_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_18_5\" class=\"gfield nhsuk-form-group gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_5'><span class='gform-field-label__text'>Email<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_18_5' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_18_6\" class=\"gfield nhsuk-form-group gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_6'><span class='gform-field-label__text'>Phone Number<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_18_6' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_18_8' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_18_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_18_2' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_18_9\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Date of Departure<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_18_9' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_18_9_2_container'><label for='input_18_9_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_18_9_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_18_9_1_container'><label for='input_18_9_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_18_9_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_18_9_3_container'><label for='input_18_9_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_9[]' id='input_18_9_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_18_10\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Date of Return<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_18_10' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_18_10_2_container'><label for='input_18_10_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_18_10_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_18_10_1_container'><label for='input_18_10_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_18_10_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_18_10_3_container'><label for='input_18_10_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_18_10_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_18_11\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_11'><span class='gform-field-label__text'>Please give details of country to be visited, length of stay, and how remote you\u2019ll be from medical help<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_18_11' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_18_12\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Type of trip<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Business'  id='choice_18_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_12_0' id='label_18_12_0' class='gform-field-label gform-field-label--type-inline'>Business<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Pleasure'  id='choice_18_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_12_1' id='label_18_12_1' class='gform-field-label gform-field-label--type-inline'>Pleasure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_12' type='radio' value='Other'  id='choice_18_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_12_2' id='label_18_12_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_13\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Holiday type<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Package'  id='choice_18_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_0' id='label_18_13_0' class='gform-field-label gform-field-label--type-inline'>Package<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Self organised'  id='choice_18_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_1' id='label_18_13_1' class='gform-field-label gform-field-label--type-inline'>Self organised<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Backpacking'  id='choice_18_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_2' id='label_18_13_2' class='gform-field-label gform-field-label--type-inline'>Backpacking<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Camping'  id='choice_18_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_3' id='label_18_13_3' class='gform-field-label gform-field-label--type-inline'>Camping<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Cruise ship'  id='choice_18_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_4' id='label_18_13_4' class='gform-field-label gform-field-label--type-inline'>Cruise ship<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_13_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_13' type='radio' value='Trekking'  id='choice_18_13_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_13_5' id='label_18_13_5' class='gform-field-label gform-field-label--type-inline'>Trekking<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_14\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Accommodation<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Hotel'  id='choice_18_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_14_0' id='label_18_14_0' class='gform-field-label gform-field-label--type-inline'>Hotel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Relatives\/family home'  id='choice_18_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_14_1' id='label_18_14_1' class='gform-field-label gform-field-label--type-inline'>Relatives\/family home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Other'  id='choice_18_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_14_2' id='label_18_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_15\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Travelling<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='Alone'  id='choice_18_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_15_0' id='label_18_15_0' class='gform-field-label gform-field-label--type-inline'>Alone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='With family\/friend'  id='choice_18_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_15_1' id='label_18_15_1' class='gform-field-label gform-field-label--type-inline'>With family\/friend<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_15' type='radio' value='In a group'  id='choice_18_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_15_2' id='label_18_15_2' class='gform-field-label gform-field-label--type-inline'>In a group<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_16\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Staying in area which is<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Urban'  id='choice_18_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_16_0' id='label_18_16_0' class='gform-field-label gform-field-label--type-inline'>Urban<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Rural'  id='choice_18_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_16_1' id='label_18_16_1' class='gform-field-label gform-field-label--type-inline'>Rural<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Altitude'  id='choice_18_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_16_2' id='label_18_16_2' class='gform-field-label gform-field-label--type-inline'>Altitude<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_17\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Planned activities<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Safari'  id='choice_18_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_17_0' id='label_18_17_0' class='gform-field-label gform-field-label--type-inline'>Safari<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Adventure'  id='choice_18_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_17_1' id='label_18_17_1' class='gform-field-label gform-field-label--type-inline'>Adventure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='Other'  id='choice_18_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_17_2' id='label_18_17_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_18_18' class='nhsuk-button nhsuk-button--reverse gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_18_18' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_18_3' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_18_3' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_18_19\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_19'><span class='gform-field-label__text'>Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_18_19' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_18_20\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_20'><span class='gform-field-label__text'>List any current or repeat medications<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_18_20' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_18_21\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_21'><span class='gform-field-label__text'>Do you have any allergies for example to eggs, antibiotics, nuts?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_18_21' class='textarea nhsuk-textarea  medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_18_22\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Have you ever had a serious reaction to a vaccine given to you before?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='Yes'  id='choice_18_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_22_0' id='label_18_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='No'  id='choice_18_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_22_1' id='label_18_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='Don&#039;t know'  id='choice_18_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_22_2' id='label_18_22_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_23\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Does having an injection make you feel faint?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='Yes'  id='choice_18_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_23_0' id='label_18_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='No'  id='choice_18_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_23_1' id='label_18_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_23' type='radio' value='Don&#039;t know'  id='choice_18_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_23_2' id='label_18_23_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_24\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Do you or any close family members have epilepsy?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='Yes'  id='choice_18_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_24_0' id='label_18_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='No'  id='choice_18_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_24_1' id='label_18_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_24' type='radio' value='Don&#039;t know'  id='choice_18_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_24_2' id='label_18_24_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_25\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Do you have any history or mental illness including depression or anxiety?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='Yes'  id='choice_18_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_25_0' id='label_18_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='No'  id='choice_18_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_25_1' id='label_18_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='Don&#039;t know'  id='choice_18_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_25_2' id='label_18_25_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_26\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Have you recently undergone radiotherapy, chemotherapy or steroid treatment?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Yes'  id='choice_18_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_26_0' id='label_18_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='No'  id='choice_18_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_26_1' id='label_18_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Don&#039;t know'  id='choice_18_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_26_2' id='label_18_26_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_18_27\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='Yes'  id='choice_18_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_27_0' id='label_18_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='No'  id='choice_18_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_27_1' id='label_18_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_18_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='Don&#039;t know'  id='choice_18_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_18_27_2' id='label_18_27_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_18_28\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_18_28'><span class='gform-field-label__text'>Please type below any further information which may be relevant<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_18_28' class='textarea nhsuk-textarea  medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_18_29\" class=\"gfield nhsuk-form-group gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' ><span class='gform-field-label__text'>Have you ever had any of the following vaccinations \/ malaria tablets?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox nhsuk_checkbox ' id='input_18_29'><div class='gchoice nhsuk-checkboxes__item gchoice_18_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.1' type='checkbox'  value='Tetanus'  id='choice_18_29_1'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_18_29_1' id='label_18_29_1' class='gform-field-label gform-field-label--type-inline'>Tetanus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_18_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.2' type='checkbox'  value='Polio'  id='choice_18_29_2'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_18_29_2' id='label_18_29_2' class='gform-field-label gform-field-label--type-inline'>Polio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_18_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_29.3' type='checkbox'  value='Diptheria'  id='choice_18_29_3'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" 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