Travel Risk Assessment

During busier periods we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

Please note that each person travelling whether an adult or a child will each need to complete an individual form to enable us to process the forms correctly.

If you have recently changed your contact details, please let us know.

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Travel Risk Assessment (NEW)

If you are human, leave this field blank.

Before completing this form please visit the following website where you will find all the information that you require on the vaccines recommended for your trip: www.travelhealthpro.org.uk

Once you have all the information on the vaccines recommended to you please complete the following form. The Nurse will then check this against your records to confirm whether you are currently protected or require up to date vaccinations. Please note that there are a cost to some vaccines, listed below. Not all of these are compulsory.

Please call the Surgery on 01264 361424, 14 days after handing us your form to arrange an appointment if necessary. Please note it is your responsibility to ensure that you follow up, the Surgery will not prompt you to book this appointment.

Full Name *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number: *

Email Address: *

Any responses we send will go to this email address.

Home Address:

Please include postcode

Please give details of country to be visited, region/areas to be visits and length of stay in each region

Please state the purpose of your holiday e.g. Resort holiday, trekking, cruise etc.

Departure date (must be 8-10 weeks after this form is submitted to ensure we can vaccinate in time if required)

DD/MM/YYYY

In order to give appropriate advice and vaccinations, it is necessary for you to answer the following questions:
All information given is strictly confidential.

Is your period late?

Yes

No

Are you pregnant?

Yes

No

Are you taking steroids?

Yes

No

Are you allergic to antibiotics?

Yes

No

Are you having chemo/radiotherapy?

Yes

No

Do you suffer a form of AIDS or at risk of HIV?

Yes

No

Are you unwell at present?

Yes

No

Do you have any allergies e.g. egg?

Yes

No

If you have answered 'yes' to any of the above please give details here:

Vaccines

Revaxis (Diptheria, Tetanus & Polio) Free

Recommended

Covered

Given

Hepatitis A (course of 2) Free

Recommended

Covered

Given

Typhoid Free

Recommended

Covered

Given

Hepatitis B (course of 3) £120

Recommended

Covered

Given

Hepatitis B Booster £50

Recommended

Covered

Given

Yellow Fever (including certificate) £70

Recommended

Covered

Given

Meningitis ACWY £40

Recommended

Covered

Given

Rabies (course of 3) £210

Recommended

Covered

Given

Maleria Advice Free

Recommended

Covered

Given

Maleria (Private Prescription) N.B. Chemist will also charge per tablet. £20

Recommended

Covered

Given

Payment must be made at time of appointment, we accept cash and debit card payments only.

*

I confirm that I have visited the above website as instructed

*

I confirm that the information provided is accurate to the best of my knowledge, and that my enquiry is not urgent - it may take up to 2 working days before I receive a reply.

Signed: *

Date: