TRAVEL CLINIC INFORMATION FORM

We are able to offer the following NHS vaccinations:

  • Diptheria, Polio, Tetanus 3 in 1 vaccine

  • Typhoid

  • Hepatitis A

We offer other private vaccination i.e Hepatitis B, for this you will incur a charge for the vaccination. Please call the practice for the price list before booking your appointment. Our nurse will be able to inform you about any vaccination that are not included in the NHS list.

IMPORTANT - Please read the following notes before completing this questionnaire.  Your vaccinations could be delayed if the form is not fully complete.

Please allow at least 4 weeks for your vaccination programme to be prepared and priced (if applicable). If your holiday is within 4 weeks please phone the surgery after 2pm on 0208 397 6361. All vaccinations should be booked at least 6 weeks before your travel date.

Once we have received your request your vaccination programme will be prepared and priced (if applicable). The final cost may differ as, during your consultation, there may be a need to alter the vaccinations suggested to suit your travel arrangements.

Contact the surgery after 2pm on 0208 394 6361 for the approximate cost of your travel vaccinations.

Please note: Please cancel your appointment in advance if you're unable to attend.

Section 1 - Personal Details

Your gender

Your gender

Section 2 - Travel Details

Have you taken out Insurance for this trip?

Have you taken out Insurance for this trip?

Do you intend to travel abroad again in the near future?

Do you intend to travel abroad again in the near future?

Type of travel and purpose of trip - please select all that apply

Section 3 - Medical Information

Please provide details of your personal medical history

Are you fit and well today?
Any allergies including food, latex, medication?
Severe reaction to vaccine before?
Tendency to faint with injections?
Any surgical operations in the past? Including, e.g your spleen or thymus gland removed.
Recent Chemotherapy/radiotherapy/organ transplant?
Anaemia
Bleeding/clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy / Seizures
Gastrointestinal (stomach) complaints
Liver or kidney problems
HIV / AIDS
Immune system condition
Mental health issues (including anxiety, depression)
Neurological  (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions not mentioned above
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?

Are you currently taking any medication?

Please tick all that apply for any vaccines or malaria tablets taken in the past

Send Your Request

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