Travel Vaccinations

Thinking of travelling at the last minute?
Hoping to book a fantastic deal on the internet
... or get a bargain at the travel agents?

That would be great but PLEASE REMEMBER WE DO NOT HAVE LAST MINUTE APPOINTMENTS.

As soon as you know you are going to be going away, please complete the form below (preferably a minimum of 6-8 weeks before you are due to travel). Our Practice Nurse will review the information and contact you to suggest appropriate vaccinations.

Not all travel vaccinations are included in the services provided by the NHS, there may, therefore, be a charge for some vaccinations. A note of any applicable charges is available from our reception or from the practice nurses.

More than one appointment may be required with the Practice Nurse to complete the vaccination course. Your final appointment should be at least 2 weeks before your date of travel to ensure immunity.

Some vaccines have to be ordered in especially for you. You will be required to pay for any chargeable vaccines in advance of them being administered to you.

There is further information about countries and vaccinations required www.fitfortravel.nhs.uk/destinations

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

Name

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

Please give dates of your stay

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

Country 2

Name

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

Please give dates of your stay

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

Country 3

Name

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

Please give dates of your stay

Please give details of your accommodation (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

Ever Had?

Typhoid

Ever Had?

Cholera

Ever Had?

Rabies

Ever Had?

Hepatitis A

Ever Had?

Polio

Ever Had?

Meningitis

Ever Had?

Yellow Fever

Ever Had?

Hepatitis B

Ever Had?

Diphtheria

Ever Had?

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?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Plas Meddyg Surgery • 40 Parkhill Road, Bexley, Kent, DA5 1HU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Key Information

Travel Vaccinations

Thinking of travelling at the last minute?Hoping to book a fantastic deal on the internet... or get a bargain at the travel agents?

That would be great but PLEASE REMEMBER WE DO NOT HAVE LAST MINUTE APPOINTMENTS.

Country 1

Country 2

Country 3

Privacy Protection

Thinking of travelling at the last minute?
Hoping to book a fantastic deal on the internet
... or get a bargain at the travel agents?