Southville Surgery Consent For Travel Immunisation Programme
Name………………………………………………………………..
Date of Birth………………………………………………………..
Address……………………………………………………………..
………………………………………………………………………
I have no reason to think that I might be pregnant. I have sought information
on the risks and benefits of the vaccines from the following:
• Travel Agent YES/NO
• Pharmacist YES/NO
• Internet (please give website details) YES/NO ………………………………
I have had the opportunity to ask questions. I consent to the vaccines being
given.
Signed…………………………………………………………………
Dated………………………………
TETANUS/DIPTHERIA/ POLIO
Yes/No
 Three injections given 4 weeks apart/ or booster. Lasts 10 years.
TYPHOID
Yes/No
 One injection that lasts 3 years.
HEPATITIS A
Yes/No
 One injection followed by a booster given 6-12 months
Please note that our nurses are not able to provide travel advice or private
prescriptions e.g. for antimalarial treatment.
Please seek advice prior to your appointment.
Recommended Travel Clinic;
Nomad Travel Clinic
38 Park Street
Bristol
BS1 5JG
01341 555 061
www.nomadtravel.co.uk
Recommended Travel Website
www.fitfortravel.nhs.uk