Travel Vaccinations

 
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All questions marked with a * are mandatory

Some vaccinations must be given prior to travel in order for them to be effective. It is important that you complete and submit the travel request for at least 6 weeks before departing ensuring you are fully protected.

  • To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.
  • We also may need to order the vaccinations that you require.
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Personal Details
Gender: *
Please double check you've entered the correct email address
May be used to identify you
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Dates and Trip Details
Please tick as appropriate below to best describe your trip
Type of trip:
Holiday type:
Accomodation:
Travelling:
Staying in an area which is:
Planned activities:
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Personal Medical History
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions): *
Do you have any allergies for example to eggs, antibiotics, nuts?: *
Have you ever had a serious reaction to a vaccine given to you before?: *
Does having an injection make you feel faint?: *
Do you or any close family members have epilepsy?: *
Do you have any history of mental illness including depression or anxiety?: *
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?: *
(Women only) Are you pregnant or planning pregnancy or breast feeding?: *
Have you taken out travel insurance and if you have a medical condition, informed the insurance company?: *
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Vaccination History

Have you ever had any of the following vaccinations / malaria tablets and if so when?

Tetanus: *
Typhoid: *
Meningitis: *
Rabies: *
Polio: *
Hepatitis A: *
Yellow Fever: *
Japanese B Encephalitis: *
Diphtheria: *
Hepatitis B: *
Influenza: *
Tick Borne Encephalitis: *
Malaria tablets: *

Vaccination Timeline

Approximately what needs to be given and when, on the days prior to departure.

31 days before

  • Hepatitis B    
  • Jap B Encephalitis    
  • Rabies    
  • Some malaria tabs    
  • Tick Borne Encephalitis

14 days before

  • Yellow Fever    
  • Dip/Tet/Polio    
  • Typhoid    
  • Hepatitis A

2 days before

  • Malaria Tablets
 

For discussion when risk assessment is performed within your appointment:

  • I have no reason to think that I might be pregnant.
  • I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions.
  • I consent to the vaccinations being given.
Signed & Dated

Privacy Consent

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