TRAVEL CLINIC INFORMATION FORM

Amendment to Services: 22/12/2015

Regrettably we are unable to offer some travel vaccinations until further notice.

We are able to offer the following NHS vaccinations:

  • Diptheria, Polio, Tetanus 3 in 1 vaccine

  • Typhoid

  • Hepatitis A

For all other vaccines please visit your local travel clinic.

IMPORTANT - Please read the following notes before completing this questionnaire.  Your vaccinations could be delayed if the form is not fully complete.

Please allow at least 4 weeks for your vaccination programme to be prepared and priced (if applicable). If your holiday is within 4 weeks please phone the surgery after 2pm on 01458 841122.

Once we have received your request your vaccination programme will be prepared and priced (if applicable). The final cost may differ as, during your consultation, there may be a need to alter the vaccinations suggested to suit your travel arrangements.

Contact the surgery after 2pm on 01458 841122 for the approximate cost of your travel vaccinations.

Please note: Failure to attend a booked travel vaccination appointment or cancellation with less than 12 hours notice may incur a charge of £20.

Section 1 - Personal Details

Section 2 - Travel Details

Section 3 - Medical Information

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