Travel Vaccinations
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Please complete the attached questionnaire as fully and completely as possible and return to
Reception
Allow 1 week for the practice nurse to review your record and then contact the surgery to
find out which vaccinations you require
Please be aware that most vaccines need to be in your system at least two to three weeks
before you travel to give the best protection against possible risk of infection
A course of vaccines may be required for some destinations, please allow plenty of time
before you travel to complete your course
A charge is made for some travel vaccines (please see below)
Please be aware that most travel vaccinations are not included within NHS services and are
offered on a private basis. If we are unable to vaccinate within your timeframe you may
have to be seen elsewhere where charges may be considerably higher
Japanese Encephalitis
Rabies
Hepatitis B
Meningitis ACWY
Tick Encephalitis
MMR
£178 course of 2
£150 course of 3
£75 course of 3
£40 course of 1
£50 per vaccine
£20 course of 1
A private prescription will be provided for malarial treatment
Payment for vaccination courses is required prior to your first appointment as some vaccinations
have to be ordered in. You need to pay in advance because sometimes patients change their
mind and when this happens the practice incurs a cost for the vaccines and may not be able to use
them for other patients if the shelf life is too short
Cheques should be made payable to Green Street Clinic.
Please remember it is the patients’ responsibility to contact the surgery to
make an appointment with the practice nurse after completion of the
Holiday Vaccination form.
Whilst we will always try to accommodate patients who have booked holidays at short notice, at
busy times this may not be possible.
PLEASE NOTE THAT WE ARE NOT A YELLOW FEVER CLINIC SO IF THIS VACCINE IS NEEDED, YOU
WILL NEED TO GO ELSEWHERE. PLEASE ASK PRACTICE NURSE FOR AN UP TO DATE LIST OF
CLINICS
Please find below alternative sources for travel vaccinations:
MASTA Travel Clinic 01273 606636
Apollo Medical Centre 01323 434100
Wish House Clinic 01273 430022
GREEN STREET CLINIC
IMMUNISATION FOR FOREIGN TRAVEL
Fill in one form for EACH traveller
SURNAME _________________________ FIRST NAMES
____________________________
ADDRESS __________________________ TEL NO
__________________________
__________________________
____________________________
AGE
__________________________
Which country are you visiting including TOWNS CITIES AND AREAS VISITED
____________________________________________________________________________
When do you leave?
__________________________________________
How long are you staying there?
_________________________________________
Are you stopping anywhere on the journey? e.g. to change flights
YES/NO
If YES, where?
________________________________________
and for how long?
_________________________ hours/days/weeks
Are you staying in a hotel or private home?
YES/NO
Will you camp or sleep rough?
YES/NO
Have you been immunised previously against? :
TETANUS
YES/NO
When? _____________ (year)
POLIO
YES/NO
When? _____________ (year)
TYPHOID
YES/NO
When? _____________ (year)
MENINGITIS
YES/NO
When? _____________ (year)
CHOLERA
YES/NO
When? _____________ (year)
YELLOW FEVER
YES/NO
When? _____________ (year)
RABIES
YES/NO
When? _____________ (year)
HEPATITIS B
YES/NO
When? _____________ (year)
HEPATITIS A
YES/NO
When? _____________ (year)
Others e.g. RUBELLA
YES/NO
When? _____________ (year)
Do you have any medical problems requiring regular supervision?
If YES, what is the problem?
YES/NO
_________________________________
Are you taking steroids?
YES/NO
Are you taking any other regular medicines?
YES/NO
Are you pregnant?
YES/NO
Have you reacted badly to any previous vaccine?
YES/NO
If YES, which vaccine?
Are you allergic to any medicines?
If YES, which?
_________________________________
YES/NO
_________________________________
I confirm the above answers to be correct to the best of my knowledge and request immunisation as appropriate to my
trip together with advice on anti-malarial drugs.
PATIENTS SIGNATURE _____________________ DATE ______________________
(parent if under 16)