PLEASE COMPLETE AND RETURN THIS FORM ASAP - SOME VACCINATIONS MUST BE
ADMINISTERED AT LEAST 2 WEEKS PRIOR TO TRAVEL
Personal details
Name:
Date of birth:
Male ( ) Female ( )
Easiest contact telephone number
Email
Dates of trip
Date of Departure
Return date or overall length of trip
Itinerary and purpose of visit
Country to be visited
Length of stay
Away from medical help at
destination, if so, how remote?
1.
2.
Future travel plans
Please tick as appropriate below to best describe your trip
1. Type of trip
Business
Pleasure
Other
2. Holiday type
Package
Self organised
Backpacking
Camping
Cruise Ship
Trekking
3. Accommodation
Hotel
Relatives/family
Other
home
4. Travelling
Alone
With family/friend
In a group
5. Staying in area which
Urban
Rural
Altitude
is
6. Planned activities
Safari
Adventure
Other
Personal medical history
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history of mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant or planning pregnancy or breast feeding?
Have you taken out travel insurance and if you have a medical condition, informed the insurance
company about this?
Please write below any further information which may be relevant
Vaccination history
Have you ever had any of the following vaccinations/malaria tablets and if so when?
Tetanus
Polio
Diphtheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other
Malaria tables
For discussion when risk assessment is performed within your appointment
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 consent to
the vaccines being given.
Signed:
Date:
FOR OFFICIAL USE
Patient Name:
Travel risk assessment performed
YES [ ]
NO [ ]
Travel vaccines recommended for this trip
Disease protection
Yes
No
Further information
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
Travel advice and leaflets given as per travel protocol
Food water and personal
Travellers’ diarrhoea
Hepatitis B and HIV
hygiene advice
Insect bite prevention
Animal bites
Accidents
Insurance
Air travel
Websites:
Travel Record card supplied
Sun and heat protection
Other
Malaria prevention advice and malaria chemoprophylaxis
Chloroquine and proguanil
Atovaquone + proguanil (Malarone)
Chloroquine
Mefloquine
Doxycycline
Malaria advice leaflet given
Further information
e.g. weight of child
Signed:
Position:
Date:
TRAVEL VACCINES
THESE PRICES ARE GIVEN AS A GUIDE ONLY.
It is advised that prior to agreeing to a course of injections you request an accurate price for
the vaccine you require.
Vaccine
Tet/dip/polio
Typhoid (Typherix)
Typhoid/Hep A
(Hepatyrix)
Hep A (Havrix Adult)
Hep A (Havrix Jnr)
Hep B (Engerix B
Adult)
Hep B (Engerix B
Paed)
Combined Hep A &
B
(Twinrix Adult)
Combined Hep A &
B
(Twinrix Paediatric)
Combined Hep A &
B
(Ambirix) Children
Only
Rabies (Rabipur)
Japanese B Enceph
(Greencross)
(Ixiaro)
Cost to Registered
Patient
Nil
Nil
Nil
Cost to NonRegistered Patient
Nil
£14.90
£48.12
Nil
Nil
£19.49 Per Vial
£33.21
£25.16
£19.49 per vial
£14.50 Per Vial
£14.50 Per Vial
Nil
£41.64
Nil
£31.19
Nil
£66.77
£54.00 Per Vial
£54.00 Per Vial
Price given on
request
£89.25 Per Vial
Men C
Nil
Meningitis ACS135Y £25.09
(ACWY)
Cholera
No charge
Malaria Tablets
Dependent on Area
Of Travel/tablets
prescribed
Private Prescription £15.00
Price given on
request
£89.25 Per Vial
Nil
£25.09
Private Script
Dependent on Area
Of Travel/tablets
prescribed
£15.00
All costs based on cost of vaccination as at 01.01.14 and are subject to price change.
All prices are exclusive of VAT @ 20%
All vaccinations are per injection unless otherwise stated
COMPLETION OF THE ATTACHED FORM
SOME COURSES OF VACCINATIONS REQUIRE A 6-8 WEEK COURSE OF TREATMENT
THEREFORE WE REQUIRE THE ATTACHED FULLY COMPLETED FORM AT LEAST 10 WEEKS
PRIOR TO TRAVEL
IT IS EXTREMELY IMPORTANT THAT THE ATTACHED FORM IS COMPLETED FULLY AND
CORRECTLY BEFORE THE NURSE CAN START ANY SEARCH. IT IS IMPERATIVE THAT YOU
RECEIVE THE CORRECT VACCINATIONS/MALARIA PROPYLAXIS ADVICE SO PLEASE MAKE
SURE THAT SPECIFIC COUNTRIES AND THE AREAS YOU INTEND TO VISIT ARE INCLUDED
TOGETHER WITH A FULL ITINERY OF YOUR TRIP – UNFORTUNATLY IF FULL DETAILS ARE
NOT COMPLETED THE FORMS WILL BE REJECTED
ONCE THE NURSE HAS COMPLETED THE SEACH – WHICH WE ARE SURE YOU WILL
APPRECIATE IS QUITE EXTENSIVE AND TIME CONSUMING – YOU WILL BE CONTACTED
PLEASE NOTE THAT ANY CHARGEABLE VACCINATIONS MUST BE PAID FOR PRIOR TO
ADMINISTRATION AND MALARIA PROPYLAXIS MUST BE PAID IN FULL BEFORE THEY ARE
ORDERED
IF YOU ARE TRAVELLING AT SHORT NOTICE IT IS STILL WORTH SEEKING HEALTH ADVICE
BUT PLEASE BE AWARE THAT THERE MAY NOT BE SUFFICIENT TIME TO COMPLETE THE
SEARCH OR ADMINISTER CERTAIN VACCINES
FURTHER INFORMATION ON TRAVEL VACCINATIONS AND HOLIDAY ILLNESSES CAN BE
FOUND ON THE INTERNET – NHS CHOICES www.nhs.uk
ENJOY YOUR TRIP!