Travel appt info updated July 2012 by b6owQ81Z


									We hope you enjoy your forthcoming holiday – you’ve chosen your destination, now time to
make sure you have the right vaccinations!

To enable you to get the right travel vaccinations please complete the form overleaf as
accurately as possible. Once you have brought it back to the practice you will be phoned by one
of our nurses to discuss which vaccinations and if necessary which malaria tablets you need.

All vaccinations except for Hepatitis B are ordered on a named patient basis. Please find a price
list of chargeable vaccinations below, all of which except men ACYW (Menveo) have to be given
at least four to six weeks before travel. There is no charge for diphtheria, tetanus, polio,
hepatitis A or typhoid vaccinations.     These vaccinations and Men ACWY (Menveo) should
ideally be given at least two weeks before departure.

In order for us to provide a safe travel service it is important that you complete the form
attached and return it to reception. A phone appointment with a Practice Nurse will then be
arranged. For this phone call you will need the following:
        Any travel record cards that you have or
        If you have registered with us in the last six months could you please obtain a full
         vaccination history from you previous GP surgery as it is unlikely that your notes will
         have been transferred.

We would recommend you look at to read more about the health
risks in the country you are visiting. This site will tell you the up to date recommended
vaccinations and malaria advice for your destination.

Charges (Prices are a guideline and can be subject to change)

Hepatitis B                   £26.50 (per injection) - course of 3 injections

Rabies                        £67.68 (per injection) - course of 3 injections

Japanese Encephalitis         £94.20 (per injection) - course of 2 injections

Ticborne Encephalitis         £65.40 (per injection) - course of 2 or 3 injections

Meningococcal (Menveo)        £63.00 (per injection) - single injection

Cholera (oral)                private prescription £12.50 plus medication charge from pharmacy
Personal details
                                                              Date of birth:
                                                              Male [ ]   Female [ ]
Easiest contact telephone number

E mail

Details of planned travel
Date of Departure:                                 Return date:

Countries and cities to be Length of stay                     Away from medical help at
visited (or please bring                                      destination, if so, how remote?

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   /            Other
                                                family home
4. Travelling             Alone                 With family /            In a group
5. Staying in area Urban                        Rural                    Altitude
which is
6. Planned activities Safari                    Adventure                Other

Personal medical history
Do you have any allergies for example to eggs, antibiotics, or nuts ?

Have you ever had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Women only: Are you pregnant or planning pregnancy or breast feeding?

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 ________ MG/ME 7/12

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