MARPLE BRIDGE SURGERY TRAVEL CLINIC
We provide routine travel vaccinations and advice for registered patients as it is always
important to ensure that your vaccinations are up to date, whether for holidays or for
business trips.
We are able to offer appointments at our Travel Clinic on Fridays between 12.45pm
and 2.45pm. If you are unable to attend at this time or if you have a particularly
complicated travel itinerary that require Japanese Encephalitis/Rabies etc. it may be
more appropriate for you to go to a Private Travel Clinic such as One Stop Travel
Clinic (905 1818). However, any free NHS vaccines will still be available from the
surgery.
The private clinics will charge you for all vaccinations given. For vaccinations given
at the surgery, some but not all are available under the NHS. Those, which are not
available under the NHS, meningitis and hepatitis B vaccinations (£37.50 per dose for
each). Where a private prescription for malaria prophylaxis is required there will be
an additional charge of £18.00 for this (the chemist will also charge for the cost of the
drugs). Private prescriptions for medication required in case of illness while abroad
£18.00
Payment to be made by cash or cheque on the day of vaccination.
Temporary residents who wish to receive travel vaccinations will be offered them on a
private basis, or they may prefer to register with the practice if this is more
appropriate.
If you wish to attend our Travel Clinic please complete the form overleaf (one for each
person travelling) and leave it at reception at least one week before telephoning to
arrange your appointment here. This ensures enough time for us to assess your
individual vaccination needs depending on your medical history, previous vaccinations
and travel plans. We can then give you an appropriate length appointment.
Please note that some vaccination programmes need to commence up to eight weeks
prior to travel. After each vaccination we ask you to remain in the surgery for twenty
minutes in case you have any adverse reactions.
Please note that no vaccinations are 100% effective and care must be taken as set out
in the health leaflet you will be given. If you are taking Lariam (Mefloquine)
antimalarial tablets you must not become pregnant within three months of completing
the course.
MARPLE BRIDGE SURGERY TRAVEL CLINIC
DATE ……………………………………………
NAME …………………………………………… DATE OF BIRTH ...…………………
ADDRESS ……………………………………………………………………………………
…………………………………………………………………………………………………
HOME TEL. NO…………………………… MOBILE NO………………………………..
Which countries do you intend to visit? Please give a detailed travel itinerary stating when and for how
long you will be in each area, including brief stopovers.
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Will you be staying in hotels or under more primitive conditions e.g. camping? ………………………
…………………………………………………………………………………………………
Does your journey include: Coastal areas? …………………… Inland areas? ……………………..
Do you plan any safaris, jungle exploring or travel in difficult terrain? ………………………………
Females only: Are you pregnant or is there any possibility you could be?
Are you allergic to anything?
……………………………………………………………………
Have you ever reacted badly to a vaccination?
Are you on any medication?
……………………………
……………………………………………………
……………………………………………………………………...
Have you had any recent illnesses or operations? …………………………………………………
Departure date ……………………………… Duration of stay …………………………………
Note: Please allow 5 working days after leaving this form before booking your appointment with the Nurse.
FOR OFFICE USE ONLY
Date received by practice……………………………………………………………………
Vaccination
Hep A
Hep B
Typhoid
Polio
Tet/Dip
Malaria
Vacc.
Recom.
Already
Covered
Vacc.
Req.
Vacc.
Recom.
Already
Covered
Vacc.
Req.
Meningitis
Rabies
Jap./Encephalitis
Tick Borne
Malaria
Length of Appt.
Practice Nurse Signature………………………Scan………………Date…………………