THE MEDICAL CENTRE GREYSTONE HOUSE

99 Station Road, Redhill, Surrey, RH1 1EB

Tel 01737 761201 Fax 01737 780510

Dr D J Aslett Dr J R Wilson Dr P C Arnold Dr J M P McGilligan Dr P C Piper Dr JH York Dr PK Patel

TRAVEL VACCINATIONENQUIRY – PERSONAL DETAILS

Please complete this form and bring it to your appointment with payment (cash/cheque/debit card only)

Please ensure you allow at least 6 weeks prior to travel

Personal Information to be completed by Patient / Traveller

Name : Date of Birth :
Address :
Tel: / GP address if not Greystone House:
Current / Repeat Medication :
Medical Conditions :
Allergies eg eggs, antibiotics, nuts latex?
Have you had a serious reaction to a vaccine before?
Do you have a personal or family history of epilepsy or depression?
Have you informed your travel insurance company about this trip?
Women : Are you pregnant / planning a pregnancy / breast feeding?
Date of departure : / Date of return:
Destinations, including stop-overs
…………………………………………………
…………………………………………………
………………………………………………… / Duration of stay at each
…………………………………………………………
…………………………………………………………
…………………………………………......
Accommodation (circle or state if other) : hotel / hostel / family home / other:
Type of Trip (circle or state if other) : Business / pleasure
Package / cruise / back packing / trekking / other
Urban / rural / altitude
Safari / adventure / other

Vaccination Information to be completed by Practice Nurse

Vaccinations Required / Travel Advice given (incl malaria) / Approx date due
Any vaccines recommended and declined by patient?

Patient Specific Directions required for Yellow Fever, Twinrix, Men ACWY, Hep B

Assessor’s Name Signature Date
Prescriber’s Name Signature Date

Consent by Recipient (or parent / guardian as applicable)

I confirm the information given above correct and understand the advice given.

I consent to receiving the vaccinations detailed and accept the associated charges.

Signed …………………………………………………….Date ………………………………….

Print name………………………..……Relationship to Patient if applicable………………………

TRAVEL VACCINATION ENQUIRY – INFORMATION SHEET

IF YOU WISH TO HAVE YOUR VACCINATIONS WITH US:

  1. Please see for which vaccinations are required
  2. Ring 01737 761 201 to book a TRAVEL appointmentallowing at least 6 WEEKS PRIOR TO TRAVEL
  3. Please complete and bring with you the attached form
  4. Please ensure you bring sufficient payment, cash, debit card or cheque (payable to Greystone House Surgery), unfortunatelycredit cards are not accepted as you need to PAY PRIOR receiving vaccines

SCHEDULE OF CHARGES

Hepatitis A (Avaxim)£50* per injection for a course of two

Booster req’d after 20 yrs

Tetanus, Diptheria Polio (Revaxis)£30*(free for children)

Typhoid (Typhim)£30*

Hepatitis A & B (Twinrix)£65*

Hepatitis A & Typhoid (Viatim)£55* (*denotes free for our registered patients)

Hepatitis B£35 per injection for a course of three injections (day 0, 1 month later, 5

months later) plus £35 for a blood test to validate protection if required. Additional charge for Booster which may be required a year later

For those at clinical risk - FREE

Occupational risk – chargeable item - employer should reimburse employee

Working abroad in a voluntary capacity- may be able to obtain their vaccinations via a specialist organisation such as Interhealth,157 Waterloo Rd, London tel. 020 7902 9000

Yellow Fever£60one injection (a Certificate of Vaccination is required)

Rabies£14.50for private prescription from the doctor

The approx cost for three injections purchased from the Pharmacy is £150, which are taken on day 0,day 7 and day 28

Meningitis ACWY£60Travellers to Saudi Arabia (the Haj and Umrah) and some parts of Africa

This vaccine is ordered in especially, if you cancel you will still be charged

Malaria TabletsChloroquine, Proguanil and combination of

These are bought from the chemist and are started 1 week prior travel

Malarone and Doxycycline

These need a private prescription, from a nurse, for purchase from the chemist and are started 1-2 days prior travel

Mefloquine

This needs a private prescription, from a nurse, for purchase from the chemist and are started 2-3 weeks prior travel

Consultation Fee £30 per consultation for non patients

Cancellation Fee £30 per patient for all patient for appointments not attended / cancelled at too short

notice to re-book

Should you have any further queries, please do not hesitate to contact us