Microsoft word - travel vaccination form_new version.doc

Ideally we require two months notice to enable us to deal with your request
Personal details
Dates of trip
Itinerary and purpose of visit (please attach any additional countries on a separate sheet)
How far away is medical help if none available at destination? Please tick below, as appropriate, to best describe your trip
Personal medical history
Please list any recent or past medical history of note, including diabetes, heart or lung conditions Please list any current or repeat medications Do you have any allergies ─ for example to eggs, antibiotics or nuts? (If yes, please list) Have you ever had a serious reaction to a vaccine given to you before? Does having an injection make you feel faint? Do you or any close family members have epilepsy? Do you have any history of mental illness, including depression or anxiety? Have you recently undergone radiotherapy, chemotherapy or steroid treatment Women only: Are you pregnant or planning pregnancy, or breast feeding?
Have you taken out travel insurance, and if you have a medical condition, informed the Please write below any further information that may be relevant Please allow 3 working days after handing in the form before contacting
the surgery for an appointment
Vaccination history
Have you ever had any of the following vaccinations or malaria tablets and if so when? For discussion when assessing risk during your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccinations recommended and have had the opportunity to ask questions. I consent to the vaccines being given. FOR OFFICIAL USE ONLY
Travel vaccines recommended for this trip (plus any further relevant information)
Travel advice and leaflets given as per protocol
Food, water and personal hygiene advice Malaria prevention advice and malaria chemoprophylaxis Further information
Data on server 1 (Q) / Practice Files / Reception / Forms, labels, slips TRAVEL VACCINATION POLICY

For travel abroad with advanced notice

• You should call into the Health centre to collect a Travel Vaccination form preferably at least two months before your departure date. • You should return your completed form preferably at least two months before you are due to go abroad This two month notice period ensures that we can process requests and book appointments in good time for vaccinations to take effect. • Once we receive the completed form a nurse will check your vaccination record against the recommended vaccinations for the country to which you are travelling. The nurse will then give the form, complete with the relevant information, to Reception • You should phone the Health Centre at least three working days after handing in the form to find out which vaccinations(if any) you require and (if necessary) to make an appointment. Please note that there is a charge for the following vaccinations
Yellow fever
Japanese encephalitis
(must be order in advance)
Tick born encephalitis
(must be order in advance)
Hepatitis B
Blood test for Hepatitis B
These prices include the administration of the vaccines

For travel abroad at short notice

• If you are departing in less than two months, we may not have a suitable nurse’s appointment available within the required timeframe. In this case, you should contact one of the following clinics for your travel vaccinations and advice. You can ask a receptionist to print out your vaccination history to take with you to the clinic. Masta Travel Clinic
Travel Clinic Limited
Travel Vaccination Clinic
You can also find out the recommended vaccinations for different countries by visiting


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