Hounsfield Surgery Travel Form
NOTE: The Surgery requires 2 months notice to enable us to deal with your request
PLEASE telephone the Surgery 10 days after returning this form and ask to speak to the
Practice Nurse to be advised if vaccinations are required
Patient Name:
Date of Birth:
Holiday Destination (multiple
destinations please give a list of
ALL destinations in the order
that you will visit them):
Holiday Start Date:
Length of Holiday Stay:
Holiday Activities:
Water
Sports
Trekking
Yes
No
Hotel
Self-Catering
Are you going on a Long Haul
Flight?
What is your Holiday
Accommodation?
Climbing Over
100,000 feet
Other
NB: Long Haul More than 5 hours
Safari
Back Pack
Other
What Regular Medication do you take?
Are you a Smoker?
No
Yes
Do you drink Alcohol?
No
Yes
Are you Pregnant?
No
Yes
Are you Breast Feeding?
No
Yes
Are you taking an Oral Contraceptive
No
Yes
Are you taking HRT
medication?
No
Yes
How many per day?
How much per week?
Please let us know if you have suffered from any of the following conditions;
Your Medical History
High Blood Pressure
Renal / Liver Problem’s
Splenectomy
Asthma
Diabetes
Skin Problems
Immunosuppressed
Depression
Epilepsy
DVT
Immunosuppressed
Epilepsy
Allergies (type)
Family History:
DVT
Patient Signature: ______________________________________________________ Date: _____________
Travel Vaccination Policy
For travel abroad with advanced notice

You should call into the Surgery 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.
NOTE: This two months’ notice period ensures that we can process requests and book
appointments in good time for vaccinations to take effect prior to your departure.

Once we receive the completed for a nurse will check your vaccination record against the
recommended vaccinations for the county / countries to which you are travelling.

You should phone the Surgery 10 working days after you have handed it in and ask to speak to
the Practice Nurse, 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 (prices will be given at the time)
Hepatitis B
3 doses required
Rabies
3 doses required
Tick born encephalitis
3 doses required
Japanese encephalitis
2 doses required
For travel abroad at short notice
 If you are departing in less than two months the surgery may not be able to assist you with
you travel vaccinations especially where you require a course or it may be difficult to make a
suitable appointment with the Practice Nurse within the available timeframe to enable the
vaccination to take effect prior to your travel.
 In these circumstances you will be require to contact one of the following MASTA clinics to
obtain your travel vaccinations and advice. The Practice Nurse will print out a copy of your
vaccination history for you to take with you to the clinic.
Boots Lincoln
Boots Nottingham
Nottingham Travel Clinic
311-312 High Street
Lincoln
Lincolnshire
LN5 7DZ
11-19 Lower Parliament Street
Victoria Centre
Nottingham
Nottinghamshire
NG1 3QS
Cripps Health Centre
University Park
Nottingham
Nottinghamshire
NG7 2QW
Telephone: 0330 100 4280
To make an appointment at either of the Boots clinics, you first need to register with MASTA. For
more information about MASTA please go to http://www.masta-travel-health.com/
Practice Staff to Complete
Practice Nurse Name: _____________________________________________ Date: ____________
Immunisation History Date of previous
immunisations
Is this Vaccine Required?
Date / Batch Number / Expiry
Date / Immunisation Site
Tetanus
Diphtheria
Polio
Typhoid
Hep A
Hep B
Men A & C / W135
Yellow Fever
BCG
Rabies
Others
Malaria Prophylaxis
Recommended? Yes
No
Check Areas being Visited ______________________________________
Special Consideration
Checked: Doctor s Name: ____________________ Signature:__________________________ Date: ______________
COSTS
Tetanus
Diptheria
Polio
Typhoid
Hep A
Hep B
Men
A&C
Yellow
Fever
BCG
Rabies
Total to be PAID IN ADVANCE (and have cleared the account if paid by cheque) by the Patient:
£_________________________ Taken By: _________________________ Date: ___________________
Other