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Travel Vaccinations

Going abroad on holiday or business? You may need travel vaccinations, depending on the country/countries you intend to visit. To help us advise you on the protection you need, please complete the form on this page, ideally 8 weeks before departure. A schedule will be worked out and ready for you to collect, approximately 3 days following the completion of the form.

You can also download the Travel Vaccine Enquiry Form and then return it to us completed.

Immunity Information

Disease

Number of Doses

Interval Between
first & second Dose

Interval Between
second & third Dose

Onset of
Protection

Duration of
Protection

Yellow Fever

one

-

-

After 10 to 14 days

10 years

Typhoid

one

-

-

After 10 to 14 days

3 years

Hepatitis A

two

3 - 6 months

-

After 10 to 14 days

10 years

Immunoglobulin (HNIG)

one

-

-

Immediate

3 - 6 months

Diphtheria*

one

-

-

Immediate

10 years

Tetanus*

one

-

-

Immediate

10 years

Polio*

one

-

-

Immediate

10 years

Meningitis

one

-

-

After 14 to 21 days

3 - 5 years

Rabies

three

7 days

21 days

2 days after last dose

2 years

Hepatitis B

three

28 days

5 months

2 days after last dose

5 years

Japanese B
Encephalitis

two

28 days

-

7 days after last dose

unknown

Tick Borne
Encephalitis

three

7 days

21 days

2 days after last dose

2 years

Cholera

two

7 to 28 days

-

7 days after last dose

3 months

*Primary immunisation required beforehand.

Travel Vaccine Enquiry Form

Personal Details
Your name: Date of birth Sex Male
Female
Contact Number: Email address:

Dates of Trip
Date of departure Return date or overall length of trip

Itinerary and purpose of visit:

Country to be visited Length of stay Away from medical help at destination, if so, how remote
What are your future travel plans:

Please check the boxes below to best describe your trip

1. Type of trip Business Pleasure Other
2. Holiday type Package Self organised Backpacking
Camping Cruise Ship Trekking
3. Accomodation Hotel Relatives / family home Other
4. Travelling Alone With family / friend In a group
5. Staying in an area which is Urban Rural Altitude
6. Planned activities Safari Adventure Other

Personal Medical History

(if not applicable please leave empty)
Do you have any recent or past medical history or note? (including diabetes, heart or lung conditions)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
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, chemotheraphy or steroid treatment?
Women only:
Are you pregnant or planning pregnancy or breast feeding?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Please enter any further details which you feel may be relevant

Vaccination History

Have you ever had any of the following vaccinations / malaria tables and if so when
Tetanus Polio
Typhoid Hepatitis A
Meningitis Yellow Fever
Rabies Jap B Enceph
Diptheria Influenza
Hepatitis B Tick Borne
Other
Malaria Tablets

Disclaimer
For discussion when risk assesment is performed within your appointment:

I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.
Do you accept the above statement?

please note the form will not send without this confirmation. 		Yes I accept Date:
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