Travel Immunisation Form

MERE SURGERY

TRAVEL IMMUNISATION FORM

This service is run by our Practice Nurses and allows you to complete details of your travel itinerary and to receive tailored advice regarding immunisations and malaria risk according to your scheduled destination(s). Please ensure you complete the form at least6 weeks before travel, and be aware that you will need an appointment with the nurse to discuss your requirements and order the necessary medications.

Requests for travel immunisations with less than 6 weeks’ notice may mean that we are unable to supply the immunisations at the surgery and you will need to contact a Private Travel Clinic. The nearest to the surgery is Salisbury, and the telephone number is 01722 342636.

Further advice for travellers can be found on the Department of Health Website:-

and following the shortcut to Health Advice for Travellers.

Information about travel vaccinations can be obtained from

Name: / Date of Birth:
Address: / Contact telephone number(s)

Please list the countries that you intend to visit. Please include any stopovers, (including short stays in airport terminals).

Dates of visit: / Today’s date
Destination Country: / Urban / Rural / Coastal / Altitude(please indicate)
Duration of Stay:
Destination Country: / Urban / Rural / Coastal / Altitude (please indicate)
Duration of Stay:
Destination Country: / Urban / Rural / Coastal / Altitude (please indicate)
Duration of Stay:
Destination Country: / Urban / Rural / Coastal / Altitude (please indicate)
Duration of Stay:

TYPE OF TRIP

Do you plan any safaris, jungle exploring or travel in difficult terrain? Yes / No

Accommodation: Hotels / camping / with friends or family / or other

Package Holiday  Cruise  Business < 3 months 

Business > 3 months  Immigration  Organised adventure holiday 

Backpacking  Aid worker  Voluntary / charity work 

Elective / student  Self-organised  Visiting family and friends 

Occupation / Activities abroad: (please list) ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Please provide any details of previous vaccinations given in the last 10 years.

Date given – month and year / Comments
Diptheria
Hepatitis A
Hepatitis B
Malaria Prophylaxis
Meningitis AC
Polio
Tetanus
Typhoid
Yellow Fever

Are you allergic to anything?Yes / No

Are you pregnant?Yes / No

Are you breast-feeding?Yes / No

Are you trying to conceive?Yes / No

Are you currently taking any medication?Yes / No

If yes please list below:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Do you have any current health problems? Yes / No

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Please hand this completed form in at reception and make a telephone appointment with a member of our Practice Nurse team who will contact you as soon as possible with your travel advice and details of any recommended immunisations.

* If you are happy for us to speak to another member of your household to discuss your travel immunisations please sign the consent section below.

* I give my consent for you to discuss my travel immunisation plan with

………………………………………………… who can be contacted on …………………………………………………-

Signature: / Date:

Please note that there may be a charge for some vaccines – A detailed list is available on request.

Charges subject to change.

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Revised August 2016