Norwich Practices Travel and Vaccine Clinic
Name
To be completed by traveller prior to making appointment
Date of Birth:
Contact details
Telephone:
Mobile:
Date of Departure
Date of Return
Travelling to?
Please give as much detail as possible including cruise reference
numbers.
Duration of stay in each
destination
Duration of trip
If multiple destinations, please try to list countries visited in order
Living conditions
Tent/ motorhome/ hostel/ hotel/ family home/ safari lodge/ other…
Type of trip
Please circle: Package holiday/ cruise/ business/ organised adventure/
backpacking/ voluntary or charity work/ visiting friends or relatives/
elective/ other
Medical history
Current:
Previous:
Current medication
(please list all, including the
contraceptive pill and nonprescription medicines)
Very important to bring record of any vaccines ever had
Allergies?
Any reaction to previous
vaccines?
Yes or no and which if known
Have you ever taken any
anti-malarias and which?
Please post completed forms to: Travel Clinic, Norwich Practices Health Centre, Rouen Road, Rouen
House, Norwich, NR1 1RB
Please allow at least 48 hours before contacting us to make an appointment on 01603 677500
PLEASE COMPLETE REVERSE
We run a Private Travel Medicine Clinic, this is a non –NHS service.
Any trip abroad you are planning should begin with a Risk Assessment. This may indicate that you
require a number of vaccines or products to prevent illness while you are away. Your GP Practice or
Travel Agent may have advised you to seek advice on vaccine requirements for your destination.
When booking your Travel Medicine appointment you are booking an appointment for a private
service and we ask you to pay a £20 non-refundable consultation fee, this is in line with other local
travel medicine service providers. Our clinic staff have specialist qualifications in Travel Medicine
and it is our aim to offer a comprehensive quality service. Should you not attend your
appointment without letting us know you forfeit the consultation fee.
Charges are made for any vaccines, products or services which you receive in the clinic in
addition to the consultation fee.
Vaccination costs are per dose (injection) the second column indicates where more than one dose
is needed to complete a course.
Cholera
2
Hepatitis A
Combined Hepatitis A and typhoid
Combined Hepatitis A&B (Twinrix) price per dose
Hepatitis B
Influenza
Japanese encephalitis (Ixiaro)
Measles, Mumps, Rubella (MMR)
Gardisil (HPV)
Meningitis Polysaccharide vaccine ACWY Nimenrix
Tic Borne encephalitis
Pertussis (Whooping cough vaccine)
Pneumovax
Rabies
Zostavax (shingles)
Typhoid
Yellow fever
Varicella (chickenpox)
Private prescription fee for travel related medicines eg Malaria tablets is £10
Children’s vaccines
1
1
3
3
1
2
2
Ambirix (A&B under 16 years)
Bexsero (meningitis B) number of doses depends on age
Engerix B paediatric (under 16years)
Hepatitis A -Havrix mono junior (ages 1-15years)
1
2
1
1
3
1
1
1
2
Private prescription fee
£10
45.00
80.00
63.00
45.00
9.00
85.00
40.00
110.00
55.00
65.00
40.00
30.00
55.00
150.00
35.00
60.00
55.00
2
2-3
3
1
62.00
100.00
25.00
30.00
3
Please be sure you understand these facts prior to booking an appointment. Please also ensure you
have sufficient funds to pay for any vaccinations, products or services received at the time of
appointment. Price list may be subject to change.
I acknowledge and understand the terms and conditions of booking an appointment at Norwich
Practices Travel Clinic
Signed………………………………………………………………….. Date…………………