Travel Vaccination Request Form

PLEASE TELEPHONE THE SURGERY 4-5 DAYS AFTER SUBMITTING YOUR FORM TO CHECK WHICH VACCINATIONS ARE REQUIRED AND TO MAKE AN APPOINTMENT WITH THE NURSE.

Personal Details Names: Age: Date of Birth (dd/mm/yyyy): Sex: Male Female GP: Please Choose... Dr SH Buxton Dr MB Wolfin Dr T Hussain Dr PW Newman Phone Number: Home Work Mobile Travel Itinery Destination: Date of depature: Length of stay: Type of trip: Please Choose... holiday business backpack other Accomodation: Please Choose... hotel (star) hostel family High risk activities: Yes No Previous / current medical history Allergies to drugs or food? Yes No Health problems? Yes No Currently taking any medication: Yes No Steroids: Yes No OCP: Yes No Pregnant: Yes No Pregnancy planned: Yes No Medical Insurance arranged: Yes No Previous vaccination history: Previous reactions to vaccine: Yes No Feel faint with injections: Yes No Tetanus: Yes No Date if applicable: Diptheria: Yes No Date if applicable: Polio: Yes No Date if applicable: Typhoid: Yes No Date if applicable: Hep A 1st or booster: Yes No Date if applicable: Hep B 1st, 2nd, 3rd, 4th Yes No Date if applicable: Meningitis:* Yes No Date if applicable: Yellow fever:* Yes No Date if applicable: Malaria: Yes No Date if applicable: Hepatitis A: Yes No Date if applicable: Hepititis B:* Yes No Date if applicable: Rabies:* Yes No Date if applicable: Other: Date if applicable: * Please note that a charge wil be made for these vaccinations / tablets Confirmation: Do you agree with the following statements? I have no reason to think that I might be pregnant. Yes No I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask question. Yes No I consent to the vaccines being given. Yes No