Travel Vaccination Form

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 vaccinations are not available free of charge on the NHS and will need to be ordered on a private prescription. These will incur a charge above the normal prescription charge.

Unfortunately, if you do not submit your questionnaire at least 8 weeks before your travel date, we will unable to provide this service for you. However, we will recommend other local travel clinics that may be able to accommodate you.

Personal Details

Name

Sex

Date of Birth

Address

Postcode

Daytime Telephone

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.

I understand

Departure

Duration

Itinerary

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

Country 1

Duration 1

Availability of Medical Help 1

Country 2

Duration 2

Availability of Medical Help 2

Country 3

Duration 3

Availability of Medical Help 3

Location Type:

Urban

Rural

Altitude

Trip Description

Please tick all appropriate boxes:

Purpose of Trip:

Business

Pleasure

Other

Accommodation:

Hotel

Friends/Family

Other

Travelling:

Alone

With Friend/Family

In a Group

Activity Type:

Safari

Adventure

Other

Personal Medical History

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)

List all allergies that you have (eg. eggs, nuts, antibiotics)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Please tick any of the following which apply

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Does having an injection cause you to feel faint?

Do you or any close family members have epilepsy?

Do you have any history of mental illness including depression or anxiety?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Have you taken out travel insurance?

If you have a medical condition, have you told your insurance company about it?

Are you pregnant, planning pregnancy or breast feeding?

Please provide any further information that might be relevant

Vaccination History

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

Tetanus

Tetanus Date

Polio

Polio Date

Diphtheria

Diphtheria Date

Typhoid

Typhoid Date

Hepatitis A

Hepatitis A Date

Hepatitis B

Hepatitis B Date

Meningitis

Meningitis Date

Yellow Fever

Yellow Fever Date

Influenza

Influenza Date

Rabies

Rabies Date

Japanese B Encephalitis

Japanese B Encephalitis Date

Tick-borne Encephalitis

Tick-borne Encephalitis Date

Malaria Tablets

Malaria Tablets Date

Other. Please specify type and date.

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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 and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

I consent to my information being used for the purposes described above and wish to submit this online form to Buckshaw Village Surgery (BVS) • Buckshaw Village Health Centre, Unity Place, Buckshaw Village, Chorley, PR7 7HZ.

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Vaccine Scheduling: Some vaccines require a series of doses spread out over a period of time. Having at least 8 weeks ensures that there is enough time to complete the full course of necessary vaccinations.

Vaccine Effectiveness: It can take a few weeks after vaccination for your body to develop full immunity. Getting vaccinated well in advance ensures that you are fully protected by the time you travel.

Availability and Appointments: Ensuring that there is ample time allows for scheduling appointments, ordering specific vaccines if they are not readily available, and addressing any potential delays in obtaining the vaccines.

Pre-travel Health Advice: Early submission of the questionnaire allows healthcare providers to offer comprehensive health advice, including information about preventing diseases and staying healthy during your travels.

Managing Side Effects: Some vaccinations might cause mild side effects. Having enough time before travel allows any side effects to resolve without impacting your trip.

Regulatory Requirements: Some countries have specific entry requirements regarding vaccinations. Providing adequate notice ensures compliance with these regulations, avoiding last-minute issues or travel disruptions.

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