Kessington Medical Centre - Travel Vaccinations

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Travel Vaccinations

Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.

Failure to complete the form correctly and in full may delay your vaccination programme.

PLEASE NOTE: IF YOU ARE TRAVELLING IN LESS THAN 6 WEEKS, WE WILL BE UNABLE TO COMPLY WITH YOUR REQUEST. PLEASE BE VERY SPECIFIC WHEN SUPPLYING US WITH TRAVELLING INFORMATION. PLEASE SUPPLY US WITH THE NAME OF THE COUNTRY, THE REGION, AREA AND TOWN YOU ARE TRAVELLING TO.

You are strongly advised to visit www.fitfortravel.nhs.uk/ to obtain the latest travel information for the area you are visiting

1Your Details

Title

First Name(s)

Surname

Date Of BirthDate Of Birth

Home address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

2Your Travel Arrangements

What date are you leaving the UK

Is the trip holiday or work?

Please give details of the type of work

3Country 1

Country 1

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

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

Please give dates of your stay

4Country 2

Country 2if none, please write none

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

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

Please give dates of your stay

5Country 3

Country 3

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

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

Will you be visiting more than 3 countries?

Please give dates of you stay

Dates of your stayDates of your stay, if more than one visit

Please give details

Are you stopping elsewhere en-route?

Please give details

6Previous immunisations

Tetanus

Date

Typhoid

Date

Cholera

Date

Rabies

Date

Hepatitis A

Date

Polio

Date

Meningitis

Date

Yellow Fever

Date

Hepatitis B

Date

Diptheria

Date

Please give details of any other vaccinations you have received

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

Have you suffered from depression or any other psychiatric illness?

Do you have epilepsy?

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

Please give details of regular medications and conditionsCurrent medications or conditions

Have you taken any steriods or had immunosuppressive therapy, i.e. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Please give details

Have you ever reacted badly to any vaccine?

Please give details

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

7For Office Use Only

For Office Use OnlyPlease do not complete this section. For internal use only

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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
Kessington Medical Centre • 85 Milngavie Road, Bearsden, Glasgow, G61 2DN.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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