TRAVEL VACCINE QUESTIONNAIRE (PLEASE GIVE FULL TRAVEL DETAILS TO

COUNTY COMMISSION REIMBURSEMENT TRAVEL VOUCHER FOR
MOUNTAIN RESTRICTIONS 1 TRAVEL IS PERMITTED ON COUNTY
TRAVEL V1 CONTENT 1 OVERVIEW 2

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0 TITLE LINE 7 TRAVELLER POLICY OFSTED SURVEY
1 MAIN ACTIVITY PACKAGE COMEXAMPLEJMAJAKTRAVEL IMPORT ANDROIDCONTENTINTENT IMPORT ANDROIDSUPPORTV7APPACTIONBARACTIVITY
1 WHILST TRAVELLING TO FAR FAR AWAY SHREK PRINCESS

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TRAVEL VACCINE QUESTIONNAIRE

TRAVEL VACCINE QUESTIONNAIRE

(Please give Full Travel Details to allow Practice Nurse to process your request appropriately).

TITLE: Mr/Mrs/Miss/Dr/Other NAME:			D.O.B.:
CONTACT TEL NO:
PREVIOUS VACCINATION HISTORY (IF KNOWN):
P regnancy? Y es No N/A No of weeks
DATE OF DEPARTURE:			DATE OF RETURN:
ITINERARY: (INCLUDING COUNTRY, REGIONS, ANY STOPOVERS OR TOUCHDOWNS)
PILGRIMAGE TO HAJ OR MECCA: (PLEASE TICK BOX)
TYPE OF TRIP: P ackage holiday C ruise B usiness < 3mths Business > 3mths	M igration O rganised adventure holiday S elf-organised holiday Backpacking	V isiting family& friends V oluntary/charity work E lective/Student A id Worker Pilgrimage		Areas to be visited U rban R ural A ltitude >3000m Beach	Accommodation G ood B asic P oor Unknown
KNOWN ALLERGIES:			ANY OTHER INFORMATION:

TO BE COMPLETED BY PRACTICE NURSE:

VACCINE	NEEDED 	RX 	ANTI MALARIALS TYPE 	NEEDED 	RX 
TYPHOID
HEPATITIS A
HEPATRIX
TETANUS
DIPTHERIA
POLIO
HEPATITIS B
JAP ENCEPHALITIS
RABIES
TICK BORN ENCEPH
MENINGITIS ACWY

RADNOR STREET SURGERY

Travel Advice Policy

Available on NHS Prescription

Diphtheria/Tetanus/Polio

Hepatitis A

Typhoid

MMR (stock)

Not available on NHS Prescription

(This also applies if you are an exemption card holder)

Hepatitis B

Rabies

Jap Encephalitis

Meningitis ACWY (Certificate for vaccination £15)

Tick – Borne Encephalitis

These vaccinations are available by Private Prescription only. A prescription is required for each person traveling and type of vaccination needed. You will also be required to pay for each item at your chosen pharmacy and there will be a charge for administering vaccinations at the surgery of £20.00.

We offer Yellow Fever vaccination at a charge of £60.00.

Malaria Advice

Chloroquine and Proguanil is purchased from your chosen pharmacy and not available on prescription.

All other malaria tablets are prescribed on a Private Prescription which carries a charge of £12.50 and you will be required to pay for these in addition at your chosen pharmacy.

Useful Information

Contact www.fitfortravel.uk to help you prepare for traveling.

Travel Clinics

Google – Glasgow Travel Clinics for full list of all Travel Clinics in Glasgow

Brownlee Centre at Gartnavel General Hospital Tel: 0141 211 1074

The Travel Clinic (Glasgow Airport) Tel: 0141 848 4800

MASTA Travel, Mitchell Street, Glasgow Tel: 0141 221 4224

10 JUNE 2005 TRAVEL DR VIRGINIE LEVASSEUR 11–18 JUNE
12 TIME TRAVEL AND CONSISTENCY CONSTRAINTS DOUGLAS N KUTACH
15 POSREDNIK CITY TRAVEL AGENCIJA ZA TURISTIČKO POSREDOVANJE NOVI

Tags: travel vaccine, the travel, travel, details, questionnaire, vaccine, (please

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