Travel Clinic

Our Clinicians are experienced in advising on vaccination and malaria requirements for all foreign travel. Please plan to see the nurse well in advance (at least eight weeks) as some schedules will take a number of weeks to complete.

Please note: Some vaccine courses are not covered by the NHS and a charge will be made, the Nurse will advise you in this case. Please complete the form below at least eight weeks in advance of your travel. Please note you will need to complete this form for each person travelling.

Travel Risk Assessment
Full Name*
Date of Birth
Please select your branch Surgery*
Primary Telephone Number*
Secondary Telephone Number
Email Address*
Gender
Date of Departure
Date of Return
Please give details of country to be visited, length of stay, and how remote you'll be from medical help:
Holiday Type
Trip Type
Staying in an area which is
Planned Activities
List any recent or past medical history of note
List any current or repeat medications
List any allergies
Does having an injection make you feel faint?*
Have you ever had a serious reaction to a vaccine given to you before?*
Do you or any close family members have epilepsy?*
Do you have any history or mental illness including depression or anxiety?*
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?*
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?*
Are you pregnant or planning pregnancy or breast feeding?*
Please write below any further information which may be relevant
Have you ever had any of the following vaccinations / malaria tablets?
Please state the date you had the following vaccinations
Tetanus
Polio
Hepatitus A
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick-borne Enceph (TBE)
Tick-borne Enceph (TBE)
Typhoid
Other / Malaria tablets please list here
*
- 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 5 working days before I receive a reply.

Travel Clinic

Travel Risk Assessment

Please state the date you had the following vaccinations