The Travel Clinic at the surgery is not part of the General Medical Services offered by your doctor, it is a private clinic .
Patients are free to go to any travel clinic (but it may be helpful to you in future if any immunisations you have elsewhere are recorded in your NHS medical record).
The administration fee for the Travel Clinic is £30 per person.
Please ensure that you come prepared to pay for the full course of vaccinations in advance. (cash or cheque please as we are unable to process payment cards)
The charges for immunisations are:-
Tetanus
Polio
Diptheria
Course free free free
Booster free free free
Diptheria + Tetanus free free
Typhoid free free
Meningitis A+C free free
Hepatitis A free free
Hepatitis + Typhoid free free
Hepatitis B £ 75 per course £ 25
Rabies £ 90 per course £ 30
Yellow Fever available at yellow fever centres ( the charge will vary depending on the clinic
)
Malaria prophylaxis
You may also be advised to take an antimalarial drug when visiting some parts of the world. If required for the countries you are visiting the practice nurse can supply you with a private prescription which you will can take to any pharmacy. (Free for those who have paid the Travel Clinic admin charge otherwise £11.50)
Travel Clinic Appointments
Date Time Date Time
1

 Please complete this form and return it to the practice.

We will contact you to arrange an appointment as soon as the nurse has decided upon the vaccination schedule you need and inform you of the cost.
 A form should be completed for each person who will be travelling.
Name………………………………Age…….
Address………………………………………………………………………
……………………………………………………………………………….
1. Can you list the countries to be visited, including any stopovers?
(Stopovers should include short stays in airport terminals)
Date of departure
Country Cities Rural areas The coast
(please tick those areas to be visited)
Length of stay
2. Will you be travelling to your destination by:
Please tick those that apply.
Aeroplane… Car… Boat… Train… Bus…
Other…. Please give details………………………………………………………………...
3. What type of transport do you expect to use while abroad?
(eg local buses, car hire, renting mopeds or bicycles)
………………………………………………………………………………………………
4. Where do you intend to say while abroad?
(e.g. international or budget hotels, guesthouses, camping or with relatives)
………………………………………………………………………………………………
2

5. What is the purpose of your travel?
(Please tick those that apply)
Holiday….. Visiting relatives/friends…...
Work – what type of work ? ……………………………………………………………….
Other – please give details: ………………………………………………………………...
6. Are you planning/anticipating doing any sporting activities?
No………. Yes (Please give details)……………………………………………………...
7. Have you had any of the following? (Please tick those that apply)
Heart problems…… Splenectomy….. Allergies…. High blood pressure…..
Breathing problems…. Diabetes… Asthma… Severe back problems……
Please give details of any other medical problems…………………………………………
8. Have you recently had any illness, surgery or dental treatment?
No…. Yes (please give details)………………………………………………………….
9. Are you pregnant? No….. Yes…..
10. Do you take any tablets?
No… Yes (please give details……………………………………………………………..
11. Do you Smoke? Yes…. No…. Drink alcohol ? Yes….. No…..
12. Please tick the following vaccinations that you have been given and the dates you had them. If you can not remember the exact date, just put in the nearest month and/or year. Please add any other vaccination details to the list and note those you are unsure about.
Vaccination Date Vaccination Date Vaccination Date
Polio
Hepatitis A vaccine
BCG
Typhoid
Diphtheria
3

Invoice
Travel clinic admin.
Required
Y/N
Y
Tetanus
Polio
Diptheria
Diptheria + Tetanus
Typhoid
Meningitis A+c
Hepatitis A free
Hepatitis A + Typhoid free
Hepatitis B
Rabies
Yellow Fever
£75 for course of 3
£90 for course of 3
Available at Yellow fever centres
Malaria Profalaxis private prescription required.
Total for attendance at travel clinic plus
required immunisations £_______
Charge
£30 free free free free free free
4