Travel Vaccinations

If you require any vaccinations relating to foreign travel you need to complete a travel questionnaire as soon as possible.

Once you have submitted this form to us, we will call you to make an appointment with the practice nurse to discuss your travel arrangements. This will include which countries and areas within countries that you are visiting to determine what vaccinations are required.

The initial appointment should be at least 6 weeks before you travel but appointments can only be made accordingly to nurse availability. A second appointment may be required with the practice nurse to actually receive the vaccinations. Some vaccines have to be ordered as they are not stocked in the surgery. Your second appointment needs to be at least 2 weeks before you travel to allow the vaccines to work.

Please note: asking you to complete a travel questionnaire does not guarantee that we will be able to provide the required vaccines. If there are vaccines that the practice nurse suggests you need but we are unable to provide them, you may visit an alternative clinic to have these vaccinations but there will be a fee for this. Your nearest clinic for travel vaccinations is: The Thorndike Medical Centre, Rochester. You will need to complete their online travel questionnaire as the same procedure as our practice. You can do this by visiting www.thorndike.nhs.uk

Charges vary depending on what vaccines are required. Please call the Thorndike Medical Centre on 01634 817217 for more information. 

If we are able to provide required vaccines, they may have to be 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.

Travelling in Europe

If you are travelling to Europe a very useful booklet has been published with advice and guidance to help you get the most out of your holiday. To visit please click:- http://ec.europa.eu/publications/booklets/eu_glance/86/en.pdf (this is a large document and may take a minute or two to view)

Appointment Details

Appointment datePlease provide in the format DD/MM/YYYY

Appointment timeHH:MM

Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

Your Travel Arrangements

What date are you leaving the UK?Please provide in the format DD/MM/YYYY

Is the trip holiday or work?

Destinations

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 2

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 3

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Tetanus

Ever Had?

Typhoid

Ever Had?

Cholera

Ever Had?

Rabies

Ever Had?

Hepatitis A

Ever Had?

Polio

Ever Had?

Meningitis

Ever Had?

Yellow Fever

Ever Had?

Hepatitis B

Ever Had?

Diphtheria

Ever Had?

Please give details of any other vaccinations you have received

Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

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

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Marlowe Park Medical Centre • Wells Road , Strood, Rochester, Kent, ME2 2PW.

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