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Foreign travel vaccination

TRAVEL CLINIC SCHEDULE (Please see read the patient information sheet before completing the schedule
You may need travel vaccinations depending on the country you intend to visit. In order to provide this advice, please complete this form and return it to Reception as soon as possible prior to
travel. You should allow at least 6 weeks prior to travel. You should contact us 14 days from the date you hand in the completed schedule PLEASE NOTE WE DO NOT CONTACT YOU! A
Travel Pack will be available for you to collect within 14 days detailing vaccinations required and Travel Health information. Private prescription charges will need to be paid when you collect the
Travel Pack. Information on Travel Health and Travel Vaccinations can be found at

Completion Date:………………………………
Name: ………………………………………………………………… Date of Birth: ……………………………………………… Tel No: Home:…………………………………… Work:…………………………………… Mobile:…………………………………. Doctor’s Name:……………………………………. Which countries, in sequence do you intend to visit? Include stop overs, however brief and be specific about areas you are visiting: ……………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… Type of Trip (please tick): Package Holiday
Occupation abroad, if relevant: …………………………………………… Will you be visiting:- Costal area  Rural area  Area over 3000m 
Do you plan any safaris, jungle exploration or travel in difficult terrain? *YES / NO If yes details:………………………………………………………………………………….…….
Departure Date: …………………………………. Length of stay:…………………………………………… Accommodation type: Camping  Hostels  Hotel  Private Home 
Have you had any of the following vaccinations and of so, when?
Vaccination
Vaccination
Vaccination
Are you allergic to anything: *YES / NO If yes details: …………………………………………………………………………………………………………………………………………… Do you have any medical problems *YES / NO If yes details: …………………………………………………………………………………………………………………. Please list your Regular Medications: ……………………………………………………………………………………………………………………………………………………………. Are you pregnant or breast feeding *YES / NO Please detail any mental health problems : …………………………………………………………………………………………I I confirm I have read the above and agree with my answers and I request vaccinations Signature: ……………………………………………………………. * Self / parent / guardian C:\Documents and Settings\Ian\Desktop\Temp Directory\Support\Kennoway\Copy of TRAVEL VACCINATION SCHEDULE.doc P:Travel Clinic/Travel Schedule (Rev Dec 2008) FOR SURGERY USE ONLY
Vaccinations Already Recorded
Vaccinations Required
Comments e.g Private Prescription/NHS Prescription
Vaccination
Date Given
Diptheria
Hepatitis A
Hepatits B
Jap B encephalitis
Meningococcal
Rabies
Swine flu
Tick borne encephalitis
Yellow Fever
Malaria Prophylaxis
Private Prescription
Documents / Information Given to Patients:
Travel Vaccination Prescription
□ (we are not a registered yellow fever clinic) Details of Charges attached to outside of envelope for patient Signature of Health professional completing vaccine schedule: ……………………………………………………. Date Schedule completed: …………………………….
Doctor’s Signature: …………………………………………………………………. (as authorisation to administer) Date: …………………………………………………
Vaccines detailed above administered by: Name: …………………………………………… Signature: ………………………………………………. Date…………………………….
----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------
FOR RECEPTIONIST/OFFICE USE ONLY

Date Schedule Issued to Patient: ___________________ Intls________ Date Completed Schedule Received from Patient ___________________ Intls _____
C:\Documents and Settings\Ian\Desktop\Temp Directory\Support\Kennoway\Copy of TRAVEL VACCINATION SCHEDULE.doc P:Travel Clinic/Travel Schedule (Rev Dec 2008)

Source: http://www.kennowaygp.co.uk/website/F20856/files/TRAVELVACCINATIONSCHEDULE.pdf

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