CRICKETFIELD SURGERY
TRAVEL VACCINATION PACK
Please complete the attached questionnaire and bring
to the surgery at least seven days prior to your
appointment with the nurse
Thank you for your enquiry regarding travel vaccinations

Please allow plenty of time to arrange your vaccinations. Some vaccinations need to be given 3
months in advance of travel.

Some vaccinations are not kept in stock, as they are not often requested. They will be ordered for
you on a named basis and kept for your use only.

In common with other local practices we cannot supply all travel vaccines on the NHS, and
consequently there may be a charge for some of your vaccinations.

Please make an appointment with the Practice Nurse for advice on travel vaccinations. You will be
advised at that first consultation of any costs involved and payment should be made before
commencement of immunisation.

Some vaccines may need to be ordered in especially for you. If there is a charge for these particular
vaccines, they will be ordered for you upon receipt of your payment.

For multiple destinations please book a double appointment.
TRAVEL VACCINATIONS
Revised May 2012
1
Depending on where you are visiting, there may be a charge for your vaccinations.
⇨
Typhoid
No Charge
⇨
Hepatitis A – (Involves 2 vaccines over 12 months)
No Charge
⇨
Hepatitis A (Children)
No Charge
(Involves 2 vaccines over a 12 month period)
⇨
Hepatitis B (course)
£90.00
(Involves 3 vaccines and a blood test)
⇨
Hepatitis B Booster
£40.00
⇨
Hepatitis B (Children)
£72.00
(Involves 3 vaccines and a blood test)
⇨
Hepatitis B Booster (Children)
£40.00
⇨
Diphtheria / Tetanus / Polio
⇨
Meningitis ACWY (each)
£45.00
⇨
MMR (Measles , Mumps and Rubella)
£25.00
No Charge
For patients over 30 years old.
⇨
Japanese Encephalitis
£170.00
(course - Involves either 2 or 3 vaccines)
⇨
Rabies - (course - Involves 3 vaccines)
(order only)
£150.00
(order only)
⇨
Rabies booster (each)
£54.00
(order only)
⇨
Tic-borne Encephalitis (course - involves 3 vaccines)
£135.00
(order only)
⇨
Cholera
⇨
Yellow Fever**
£45.00
Please contact Albany
Surgery direct.
**The nearest Yellow Fever Centre is Albany Street Surgery, Newton Abbot
Revised May 2012
2
TRAVEL HEALTH QUESTIONNAIRE
First Names
Surname
Date of Birth
Contact Number
Duration of Trip
Departure Date
Please list all the countries you will be visiting,
including stop overs.
Destinations
Please circle the type of areas you will be visiting: Mountainous/ Rain Forest/ Rural/ Resort/ Other.
Please circle the type of accommodation you will be staying in: Hotel/ Private House/ Camping/
Backpacking/ Trekking.
Type of Visit: Business/Holiday Are you Pregnant or planning pregnancy: Yes/ No
Are you taking steroids: Yes/ No
Have you had any recent treatment for cancer: Yes/ No
Have you reacted badly to any previous vaccines: Yes/ No
Vaccination to
be given by
Practice
Nurse
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Recommended
for Travel
Date
Given
Vaccinations
recommended
for Travel
B.C.G
Japanese
Encephalitis
Yellow Fever
Tick Bourne
Encephalitis
Meningitis
ACWY
Cholera
Vaccinations
authorised by
GP
Date
Given
Please contact Albany Surgery
Rabies
Patient Consent: I have received and understood the advice given to me concerning:
Travel Vaccination Requirements  Anti- Malarial prophylaxis 
General Preventative Measures  For Myself  For My Child 
SIGNATURE…………………………………………….DATE…………………………………….
Revised May 2012
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