Travel Vaccinations

If you require any vaccinations relating to foreign travel you need to make an appointment with the practice nurse to discuss your travel arrangements. This will include which countries and areas within countries that you are visiting to determine what vaccinations are required. There is further information about countries and vaccinations required on the links below

It is important to make your appointment as early as possible - at least 6 weeks before you travel so that the nurse can do a thorough risk assessment, give you appropriate travel advice and give your vaccinations in time prior to your trip.

We provide the vaccines which are available for free via the nhs.

This includes vaccinations against Hepatitis A, Typhoid, Tetanus, Diphtheria, Polio, Measles, Mumps, Rubella and Cholera.

All other vaccines, such as Rabies, Japanese Encephalitis, Tick-borne Encephalitis, Hepatitis B, Yellow Fever and Meningitis ACWY (for travel purposes such as pilgrimage) are private vaccines which can be sourced via a private travel clinic. There are charges for these vaccines.

Anti-Malarial medication can be purchased from a private travel clinic. Some pharmacies offer private travel clinic services.

Please complete the form below, or alternatively you can collect a form from reception. This must be completed before your appointment so the nurse can be prepared for your consultation.

Appointment Details

Appointment datePlease provide in the format DD/MM/YYYY

Appointment timeHH:MM

Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

Your Travel Arrangements

What date are you leaving the UK?Please provide in the format DD/MM/YYYY

Is the trip holiday or work?

Destinations

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1

Country 1 Name

Which area are you staying in in country 1? (Please be exact)

Please give dates of your stay in country 1

Please give details of your accommodation in country 1 (hotel, private house, camping etc)

Country 2

Country 2 Name

Which area are you staying in in country 2? (Please be exact)

Please give dates of your stay in country 2

Please give details of your accommodation in country 2 (hotel, private house, camping etc)

Country 3

Country 3 Name

Which area are you staying in in country 3? (Please be exact)

Please give dates of your stay in country 3

Please give details of your accommodation in country 3 (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Tetanus

Have you ever had a tetanus immunisation?

Typhoid

Have you ever had a typhoid immunisation?

Cholera

Have you ever had a cholera immunisation?

Rabies

Have you ever had a rabies immunisation?

Hepatitis A

Have you ever had a hepatitis A immunisation?

Polio

Have you ever had a polio immunisation?

Meningitis

Have you ever had a meningitis immunisation?

Yellow Fever

Have you ever had a yellow fever immunisation?

Hepatitis B

Have you ever had a hepatitis B immunisation?

Diphtheria

Have you ever had a diptheria immunisation?

Please give details of any other vaccinations you have received

Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

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