Reception: Travel Form

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

The practice offers travel advice and vaccines that are available free on the NHS. These are listed below:

Polio (given as the combined diphtheria/tenanus/polio)
Typhoid
Hepatitis A
Cholera

We DO NOT provide the following vaccines:

Hepatitis B
Japanese Encephalitis
Meningitis
Yellow Fever
Rabies
Tick-borne encephalitis
Tuberculosis (TB)

These vaccines can be obtained from a Travel Clinic. This service is offered by most large retail Pharmacies.

Once you have completed the form you will contacted by either text or a phone call.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 8 weeks to complete. Please DO NOT call before 4 weeks of submission as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Your Details

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Your Travel Arrangements

What date are you leave the UK?

Is the Trip holiday or work?

Destinations

Country 1:

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

Arrival Date:

Leaving Date:

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

Country 2 (leave blank if not applicable)

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

Arrival Date:

Leaving Date:

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

Country 3 (Leave blank if not applicable)

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

Arrival Date:

Leaving Date:

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

Will you be visiting more than three countries?

If YES then please give full details below:

Previous Immunisations

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

Tetanus (If yes please document in an approximate date):

Typhoid (If yes please document in an approximate date):

Cholera (If yes please document in an approximate date):

Rabies (If yes please document in an approximate date):

Hepatitis A (If yes please document in an approximate date):

Polio (If yes please document in an approximate date):

Meningitis (If yes please document in an approximate date):

Yellow Fever (If yes please document in an approximate date):

Hepatitis B (If yes please document in an approximate date):

Diphtheria (If yes please document in an approximate date):

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?

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

Are you allergic to any medicines? (Write 'none' if you have no allergies)

Have you ever reacted badly to any vaccine? (Please type details if this is 'Yes')

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

Please note that it will take 8 weeks to complete the full process including any immunisations you may need administered.

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 Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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