Warley Medical Centre Travel Service
Including Yellow Fever Vaccination
Please complete the attached form with the details of your proposed itinerary and dates of travel.
We also need your medical details especially if you are not a patient in this
Practice and need yellow fever vaccination.
You will need to submit this form so we can plan your necessary immunisation program so please give us as
much notice as possible. The completed form should be handed to the receptionist. Please call after 7 days
when details of the appointment required will be available – for some travellers previous vaccinations will cover
you for your travel and an appointment will not be needed.
Certain travel vaccines needed for most countries are available on the NHS and there is no charge.
Most Malaria tablets can be obtained without prescription from the chemist. If a prescription is required this is
a private prescription and the cost is £5. You will pay the chemist an additional charge for the medication
Complicated travel regimes
Certain vaccines do incur a charge – these are only available on private prescription and are not available on
the NHS, vaccines such as Rabies, Hepatitis B and more unusual vaccines. For these a charge is made of
£15 for each course of vaccine given (most need 2-3 vaccines to give protection) – a private prescription will
be provided (included in the cost) but you will need to pay the pharmacist for the vaccine.
Yellow Fever Advice
If you require yellow fever vaccination alone and have been given travel advice by your own GP you will still
need to complete the form as there are certain conditions in which the vaccine is not advised. Yellow fever
vaccine is mainly required for visits to Africa and South America, and details of the countries where this is
required change on a regular basis – in some countries there is no risk but a vaccination certificate may be
required if you have been to an area of risk. Details of your itinerary are therefore required. Yellow fever
vaccination covers you for 10 years and is not valid until 10 days after immunisation so you may not be
allowed in the country if you have a certificate which is not valid.
The cost for yellow fever vaccination for a patient registered with this practice is £45. For other travellers a
£10 non refundable administration charge is made when an appointment is made for the vaccine – this is
deducted from the £55 cost when the vaccine is given. This cost includes the certificate of vaccination.
PLEASE FILL IN THE FOLLOWING
Name
Address
Doctors name and address if not our patient
____________________________________________________________________________________
FOR RECEPTION USE
Date received ____________________________ Received by __________________________________
Date given to nurse _______________________ Date of Appointment ____________________________
Recommended appointment YES
NO
More than one for complicated regime number required __________________
Charges – Yellow Fever _______________________ other vaccination prescriptions ________________
Please describe your travel plans including details of itinerary and any transfers of stopovers
Countries to be visited, date of travel and length of stay
Please describe your trip ticking the boxes which apply
Type of trip
Holiday Type
Accommodation
Area is
Business
Pleasure
Other
Package
Camping
Cruise
Trekking
Hotel
Family/Friend
Other
Urban
Rural
Altitude
Backpacking
Safari
Adventure
Are you travelling alone or in a group?
CONSENT
I Consent to receive the recommended vaccines for my travel arrangements. I have received
Information on the risks and benefits of the vaccine and have had the opportunity to ask questions.
For women only – I have no reason to believe that I am pregnant.
Signed:
Date:
WARLEY MEDICAL TRAVEL RISK ASSESSEMNT FORM
All questions in this questionnaire are strictly confidential and will become a part of your medical record
Name:
Telephone number:
Are you registered here? Yes
Male
Female
No
Age:
DOB:
NHS Number:
Previous vaccination history
Immunisations
and dates (if
known)
Tetanus
Diphtheria
Polio
Pertussis
Hepatitis A
Hepatitis B
Influenza
Pneumococcal
TB - BCG
Menigitis
Yellow Fever
MMR
Rabies
Japanese encephalitis
Cholera
Typhoid
Others
List below any medical problems you may have
List below any medication you are taking including any you may receive from hospital.
Dose
Medication
How often do you take it
Please answer the following questions
Yes
No
Details
Do you have any allergies or have had an allergic
reaction in the past?
Are you allergic to eggs?
Women only – are you pregnant or planning a
pregnancy or breastfeeding
Are you taking steroids or immunosuppressive drugs?
Have you had cancer treatment in the last 6 months –
includes radiotherapy and chemotherapy?
Have you ever had a bone marrow transplant?
Do you have epilepsy?
Have you had a previous reaction to a vaccine?
Do you have a thymus disorder?
Additional Information:
Please include any relevant information or queries you have.
It is your duty to inform your travel insurance company of any
Medical conditions you have or have had in the past,