The Cross Keys Practice Travel Vaccination Request Form

Please complete a separate Travel Vaccination request form for each individual
traveller.

Where possible complete this form at least 8 weeks before your departure date as
some vaccinations require more than one dose and can take 4 weeks to give full
protection.

A Travel Vaccination appointment can be made when you send/ drop off your form.
Or alternatively you can ring a week later to find out what has been recommended.

If less than two weeks notice is given it is unlikely we will be able to offer an
appointment.

We also process Travel Vaccination requests through our website:
www.crosskeyspractice.co.uk

Please note that no vaccine offers 100% protection and a small proportion of
individuals get infected despite vaccination.
Surname:
Forename:
Date of Birth:
Departure Date:
Length of stay:
Telephone number:
Countries to be visited including stopovers:
Special considerations: e.g. backpacker, safari, rural areas to be visited, school trip, aid
worker:
Are you pregnant, breast feeding or planning a pregnancy?
Do You Smoke? Y / N
Daily Amount:-
Please record any allergies (drugs/food)
Are you undergoing chemotherapy/radiotherapy or have you in the past 6 months?
There is a charge for some vaccines and private prescriptions.
Prices are per dose.
Hepatitis B £44 (primary course is 3 doses) Rabies £72 (primary course is 3 doses)
Japanese encephalitis £125 (primary course is 2 doses) Yellow fever £71
Meningitis ACWY £68
Private prescriptions £5
PTO
Please enter dates of the vaccinations you have received. This is particularly useful if you have had
vaccinations outside general practice, such as at school or work.
NB If you are an unregistered patient you can have travel immunisations as a temporary
patient. For this you need to fill in a temporary resident form and ask the surgery where you
are registered to email your immunisations to [email protected] or fax to 01844
271606
Diphtheria
Tetanus
Polio
Hepatitis A
1
2
Hepatitis B
1
2
3
Japanese Encephalitis
Yellow Fever
Typhoid
Rabies
1
2
3
Tick borne encephalitis
Meningitis C
Meningitis A&C
Meningitis ACWY
Other
For completion by Surgery Administration only:
Date Received
Date processed
IMMUNISATIONS RECOMMENDED
(R=strongly recommended S=sometimes recommended)
Diphtheria /Tetanus/Polio
Hepatitis A
Yellow Fever
Typhoid
Hepatitis B
Rabies
Meningitis ACWY
Japanese encephalitis
Tick borne encephalitis
Cholera
MALARIA CHEMOPROPHYLAXIS
Advice only
Mefloquine (Larium)
Chloroquine
Malarone
Paludrine
Doxycycline
GP AUTHORISATION FOR VACCINES
GP signature:
Date:
Download

Travel Vaccination form - The Cross Keys Practice