The Tardis Surgery

Travel Vaccinations

To make it easier for our patients you can now complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs, after completing and submitting the form below contact the surgery to make an appointment with the practice nurse. The nurse will then be able to give you the correct vaccinations for your travel.

Failure to complete the form correctly and in full may delay your vaccination programme.

1Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of Birth

2Your Travel Arrangements

What date are you leaving the UK?

Is the trip holiday or work?Please Choose...HolidayWork

3Destination(s)

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

Country 1

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

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

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?Please Choose...YesNo

Are you stopping elsewhere en-route?Please Choose...YesNo

If you have answered yes to either of the two previous questions, please provide details

4Previous Immunisations

If you have had the following immunisations please provide the date given

Tetanus

Typhoid

Cholera

Rabies

Hepatitis A

Hepatitis B

Polio

Meningitis

Yellow Fever

Diphtheria

Please give details of any other vaccinations you have received

5Further Information

Have you had any antibiotic treatment in the last 8 weeks?Please Choose...NoYes

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

Do you have epilepsy?Please Choose...NoYes

Do you have medical problems requiring regular medication or check ups?Please Choose...NoYes

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

Are you allergic to any medicines?Please Choose...NoYes

Have you ever reacted badly to any vaccine?Please Choose...NoYes

Are you pregnant or planning a pregnancy in the next 6 months?Please Choose...NoYes

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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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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.

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