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Travel Vaccination Form

If you require any vaccinations relating to foreign travel you will need to complete a Travel Health Questionnaire. You must submit the questionnaire at least 8 weeks before the date of travel, but we advise you do this as early as possible. We insist on at least 8 weeks’ notice because;

  • The nursing team need sufficient time to safely check your region of travel; sometimes different regions of the same country have different advice/vaccination requirements.
  • We may have to order some vaccinations in, especially less common ones.
  • You may require more than one dose of a vaccination, spread over several weeks.
  • If there is a group of people travelling together, each patient will need separate appointments for their vaccinations, this can be problematic to schedule.

The Health Questionnaire allows the Nursing team to assess your health needs, it is very important you include the region of the country you are visiting as this can impact on the advice or vaccinations required. You can complete the questionnaire online, via the link below or collect a printed copy at Main Reception.

Once you have submitted your questionnaire the nurse will check the information and then the surgery will contact you to arrange a suitable appointment. You will be advised if there are any costs related to the vaccinations. Some travel vaccines are ordered on a private prescription and these incur a charge over and above the normal prescription charge. This is because not all travel vaccinations are included in the services provided by the NHS.

Please note if you do not submit your questionnaire at least 8 weeks before your travel date, we will be unable to see you; however we may be able to recommend other, local travel clinics that may be able to accommodate you.

Travel Health Questionnaire

*** PLEASE NOTE BEFORE COMPLETING THE QUESTIONNAIRE ***

  • If you do not submit your questionnaire at least 8 weeks before your travel date, we will be unable to see you; however we may be able to recommend other, local travel clinics that may be able to accommodate you.
  • To avoid unnecessary delays please include your region of travel as well as Country as this may alter what vaccinations are required.

To help us offer the appropriate advice, please fill out the online form below before coming to see the nurse.

Personal Details
Trip Dates

If you do not submit your questionnaire at least 8 weeks before your travel date, we will be unable to see you; however we may be able to recommend other, local travel clinics that may be able to accommodate you.

Itinerary

PLEASE MAKE SURE YOU INCLUDE REGION OF TRAVEL AS WELL AS COUNTRY

Trip Description

Please tick all appropriate boxes:

Personal Medical History
Vaccination History

Have you ever had any of the following vaccinations / tablets and if yes please tick the box and provide the date.


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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