Name: ….…………….….……D.O.B………………………
Address: ….………….…………….……………………………………
……………………………………….……………… Postcode: …………………
Tel: …………………………………. Mobile: .….………………………………
General health: Do you smoke? Yes/No Height________________
Yellow Fever minimum 10 days prior to travel:
Weight ______________________
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Re-issue certificate (only if given at this surgery).
• Please list destination(s) of travel, (in date order if more than one)
• For each destination, write how long you will be in each country:
………………………………………………………………………………………….
Private prescription + administration of vaccine
NB you will need to collect and pay for the vaccine
…….…………….………….…………………………………………………….……
from the chemist and store in fridge
…………………….……………………………………………………………………
Duration of Trip: ….……….……………………………………………………….
Date of Departure: ….……….………………………………………………….
Rabies Course of 3 injections (over 28 days):
Type of trip (eg holiday, businesss etc) ……….….……….………………….
Private prescription + administration of vaccines
NB you will need to collect and pay for the vaccine from the
Information on vaccination & malaria prevention recommendations for all
chemist and store in fridge
countries can be found at www.fitfortravel.scot.nhs.uk and we recommend you
look at this before your appointment if you have access to the internet
Japanese Encephalitis Course of 2 injections (over 28 days):
Please book an appointment if the Travel Nurse has ticked any of
Last injection minimum 10 days prior to travel.
Private prescription + administration of vaccines
the items opposite. You may need more than one appointment
NB you will need to collect and pay for the vaccine
according to your vaccination requirements
from the chemist and store in fridge. Remember to bring this leaflet to your appointment.
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Tickborne Encephalitis Course of 3 injections
The nurse will tick an appropriate box below;
Private prescription & administration of vaccines
NB you will need to collect and pay for the vaccine from the 10 min General appointment. 20 min Travel appointment. chemist and store in the fridge 30 min Travel clinic appointment.
You are currently up to date with all recommended vaccinations
Proguanil and chloroquine. Buy from chemist without prescription
There are no vaccinations recommended for your trip
NB you will then need to buy the tablets from the chemist
Form - Travel Imms – 01/04/11 Travel Health
Many health problems associated with travel abroad cannot be prevented by vaccinations alone & therefore it is essential that you
Hook and Hartley Wintney Medical
take measures to protect your health whilst travelling.
Partnership
Before seeing our practice nurses we strongly recommend that you have obtained information on the potential health risks associated
with your destination, and the specific risks that your type of travel and length of stay might incur.
If you are travelling to a European Country or Switzerland we
Travel Clinics
recommend you obtain a ‘European health Insurance Card’ (EHIC –
replacement for E111). This entitles you to reduced cost or free medical treatment that becomes necessary whilst you are in a
European country or Switzerland. You are strongly recommended to arrange travel insurance on top of this.
You can apply for this online: www.dh.gov.uk/policyandguidance/healthadvicefortravellers/fs/en By phone: 0845 606 2030 Or you can collect the form with pre-paid envelope from the Post Office You will need your National Insurance or NHS number
When the travel nurse has looked at your request and given recommendations for your trip, this form will be posted back to you. Please fill in a form for each member of your family.
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Form - Travel Imms – 01/04/11