Norwich PracticesTravel and Vaccine Clinic

To be completed by traveller prior to makingappointment

Name / Date of Birth:
Contact details / Telephone:
Mobile:
Date of Departure
Date of Return
Travelling to? / Please give as much detail as possible including cruise reference numbers.
Duration of stay in each destination
Duration of trip / If multiple destinations, please try to list countries visited in order
Living conditions / Tent/ motorhome/ hostel/ hotel/ family home/ safari lodge/ other…
Type of trip / Please circle: Package holiday/ cruise/ business/ organised adventure/ backpacking/ voluntary or charity work/ visiting friends or relatives/ elective/ other
Medical history
Current:
Previous: / Very important to bring record of any vaccines ever had
Current medication
(please list all, including the contraceptive pill and non-prescription medicines)
Allergies?
Any reaction to previous vaccines? / Yes or no and which if known
Have you ever taken any anti-malarias and which?

Please post completed forms to: Travel Clinic, Norwich Practices Health Centre, Rouen Road, Rouen House, Norwich, NR1 1RB

Please allow at least 48 hours before contacting us to make an appointment on 01603 677500

PLEASE COMPLETE REVERSE

We run a Private Travel Medicine Clinic, this is a non –NHS service.

Any trip abroad you are planning should begin with a Risk Assessment. This may indicate that you require a number of vaccines or products to prevent illness while you are away. Your GP Practice or Travel Agent may have advised you to seek advice on vaccine requirements for your destination.

When booking your Travel Medicine appointment you are booking an appointment for a private service and we ask you to pay a £20 non-refundable consultation fee, this is in line with other local travel medicine service providers. Our clinic staff have specialist qualifications in Travel Medicine and it is our aim to offer a comprehensive quality service. Should you not attend your appointment without letting us know you forfeit the consultation fee.

Charges are made for any vaccines, products or services which you receive in the clinic in addition to the consultation fee.

Vaccination costs are per dose (injection) the second column indicates where more than one dose is needed to complete acourse.

Cholera / 2 / Private prescription fee £10
Hepatitis A / 1 / 45.00
Combined Hepatitis A and typhoid / 1 / 80.00
Combined Hepatitis A&B (Twinrix) price per dose / 3 / 63.00
Hepatitis B / 3 / 45.00
Influenza / 1 / 9.00
Japanese encephalitis (Ixiaro) / 2 / 85.00
Measles, Mumps, Rubella (MMR) / 2 / 40.00
Gardisil (HPV) / 3 / 110.00
Meningitis Polysaccharide vaccine ACWYNimenrix / 1 / 55.00
Tic Borne encephalitis / 2 / 65.00
Pertussis (Whooping cough vaccine) / 1 / 40.00
Pneumovax / 1 / 30.00
Rabies / 3 / 55.00
Zostavax (shingles) / 1 / 150.00
Typhoid / 1 / 35.00
Yellow fever / 1 / 60.00
Varicella (chickenpox) / 2 / 55.00
Private prescription fee for travel related medicines eg Malaria tablets is £10
Children’s vaccines
Ambirix (A&B under 16 years) / 2 / 62.00
Bexsero (meningitis B) number of doses depends on age / 2-3 / 100.00
Engerix B paediatric (under 16years) / 3 / 25.00
Hepatitis A -Havrix mono junior (ages 1-15years) / 1 / 30.00

Please be sure you understand these facts prior to booking an appointment. Please also ensure you have sufficient funds to pay for any vaccinations, products or services received at the time of appointment. Price list may be subject to change.

I acknowledge and understand the terms and conditions of booking an appointment at Norwich Practices Travel Clinic

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