Healthcare Registered Private Doctors
The Independent General Practice
Consent Form – Travel
____________________________________________________________________________________________________________________________
Under this contract, The Independent General Practice (IGP) will provide medical consultation, treatment, examination, diagnostic and management
medical services to patients who present. The IGP agrees to fully respect the needs of their patients. They undertake to practice within their capabilities
and to refer to specialist practitioners where they deem appropriate. Facilities will be regularly monitored and updated, with equipment being
calibrated and serviced on a regular basis.
In return for these services, patients will be charged. These must be settled prior to leaving the premises, unless we have agreed an alternative
payment method.
Please indicate whether you require a chaperone to be present when you see the Doctor or Nurse:
Yes
No
Patient Details: (This part of the form needs to be completed with the details of the person seeing the Doctor)
Title: _____________ Name: __________________________________________________________ Date of Birth: ______________________________
Address: ____________________________________________________________________________________________________________________
___________________________________________________________________________ Postcode: ________________________________________
Contact Number: ____________________________________________ Email: ___________________________________________________________
Consent Declaration:
I can confirm that:




I have no reason to think that I might be pregnant.
I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions.
I therefore consent to the treatment / vaccines being given.
I also consent to the IGP informing my NHS GP of these vaccinations.
NHS GP Name: _______________________________________________________________________________________________________________
NHS GP Address: ______________________________________________________________________________________________________________
Patient’s (Parent’s) Signature: _____________________________________________________ Date: ________________________________________
From time to time The IGP may like to contact you with information relating to our services. If do not wish to be contacted, please tick here
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Liability: Except in respect of death or personal injury caused by the Company’s negligence, the Company shall not be liable to the Patient by reason of any representation or any implied warranty,
condition or other term or any duty of common law or under the express terms of the Contract for any consequential loss or damage (whether for loss of profit or otherwise) costs, expenses or other
claims for consequential compensation whatsoever (and whether caused by the negligence of the Company its employees or agents or otherwise) which arise out of or in connection with the
performance of the Services and supply of the Goods or their use or resale or disposal by the Patient except where expressly provided in these Conditions. The Company will limit any liability to the extent
of the Company’s insurance cover.
Data Protection: The IGP complies with Data Protection Act 1998 and will be the controller of any data taken during your treatment/care. Information concerning your health will be kept confidential.
However, the information you give us may be recorded, shared and/or used in line with agreed medical treatment/care and any necessary subsequent administration. It may also be used, on an
anonymous basis, to support any local clinical audits and other work to monitor the quality of care provided. You have a right to access your own medical records. Details on how we manage your data is
available in the "Fair Processing Notice" within our "Patient Guide". This is available on request from any of our locations and to download from www.theigp.co.uk. Version No: 002 – 01/02/2012
Healthcare Registered Private Doctors
The Independent General Practice
Risk Assessment Form – Travel
____________________________________________________________________________________________________________________________
Itinerary & Purpose of Visit
Destination(s)
Date of Travel:
Length of stay
Type of Trip:
Business
Pleasure
Other
Holiday type:
Package
Self-Organised
Back Packing
Camping
Cruise Ship
Trekking
Accommodation:
Hotel
Relatives / Family Home
Other
Company:
Alone
With Family / Friend(s)
In a Group
Area:
Urban
Rural
Altitude
Planned activities:
Safari
Adventure
Other
Away from medical help, if so, how long for?
Vaccination History - Have you ever had any of the following vaccinations / Malaria tablets and if so when?
Tetanus
Polio
Diphtheria
Meningitis
Hepatitis A
Typhoid
Hepatitis B
Rabies
Jap B Enceph
Tick Borne
Yellow Fever
Malaria tablets
Influenza
Other
Please provide details of any other vaccine(s) you have had:
Please write any further information which may be relevant:
Do you have a history of allergy, blood disorder, poor immunity, serious illness (diabetes, heart, lung conditions, thymus)?
Yes
NO
Are you on any current Medication?
Yes
NO
Have you ever had a serious reaction to a vaccine given to you before?
Yes
NO
Do you have any allergies for example to eggs, antibiotics, nuts?
Yes
NO
Do you have any allergies for example to eggs, antibiotics, nuts?
Yes
NO
Does having an injection make you feel faint?
Yes
NO
Do you or any close family members have epilepsy?
Yes
NO
Do you have any history or mental illness including depression or anxiety?
Yes
NO
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Yes
NO
Women only: Are you pregnant or planning pregnancy or breast feeding?
Yes
NO
Have you taken out travel insurance & informed the insurance company of any medical condition?
Yes
NO
If YES to any of the above, please provide details:
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Healthcare Registered Private Doctors
The Independent General Practice
Risk Assessment Form – Travel
____________________________________________________________________________________________________________________________
For Doctor’s Use Only
Risk Assessment Completed?
YES
NO
TRAVEL ADVICE AND LEAFLETS GIVEN AS PER TRAVEL PROTOCOL
Food water & personal hygiene advice
Insurance
Hepatitis B and HIV
Insect bite prevention
Animal bites
Accidents
Travellers’ diarrhoea
Air travel
Sun and heat protection
Travel record card supplied
Websites
Other
MALARIA PREVENTION ADVICE and MALARIA CHEMOPROPHYLAXIS
Chloroquine & Proguanil
Atovaquone & Proguanil (Malarone)
Chloroquine
Mefloquine
Doxycycline
Malaria advice leaflet given
Further Information (e.g. weight of child): _________________________________________________________________________________________
Vaccinations: ________________________________________________________________________________________________________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Vaccine: ________________________ Batch Number:
Expiry date: _________________ Vaccine Number: __________________
Payment Details:
PART
FULL
Amount: £ ________________________________________________________________________
Practitioner’s Signature: ___________________________________________________________ Date: _______________________________________
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