LAURENCEKIRK MEDICAL CENTRE

ADVICE AND IMMUNISATION FOR FOREIGN TRAVEL.

Please return this completed form to reception. Telephone 7-14 days later to be advised if an appointment is required for vaccines. If vaccines are required, you will have to pick up a prescription for these before your appointment. There will be a small charge for vaccines not available from the NHS. If you have a vaccine record card, bring it along to your appointment. Advice leaflets available on

This form will not be accepted if departure is less than 3 weeks.

PERSONAL DETAILS

NAME
DATE OF BIRTH Male [ ] Female [ ]
EASIEST CONTACT TEL NO.
E MAIL
WEIGHT (IMPORTANT FOR CHILDREN)

DATES OF TRIP

DATE OF DEPARTURE
RETURN DATE OR DURATION OF TRIP

INTINERARY AND PURPOSE OF TRIP

COUNTRY TO BE VISITED(AND WHICH AREA OF COUNTRY) / LENGTH OF STAY / WILL YOU BE MORE THAN 48HRS AWAY FROM MEDICAL HELP DURING YOUR STAY?
1
2
FUTURE TRAVEL PLANS

PLEASE TICK APPROPRIATE BOX TO BEST DESCRIBE YOUR TRIP

1. TYPE OF TRAVEL / BUSINESS / PLEASURE / OTHER
2. HOLIDAY TYPE / PACKAGE / SELF ORGANISED / BACKPACKING
CAMPING / CRUISE SHIP / TREKKING
3. ACCOMMODATION / HOTEL / RELATIVES/FAMILY HOME / OTHER
4. TRAVELLING / ALONE / WITH FAMILY/FRIEND / IN A GROUP
5. STAYING IN AREA WHICH IS / URBAN / RURAL / ALTITUDE
6. PLANNED ACTIVITIES / SAFARI / ADVENTURE / OTHER

PERSONAL MEDICAL HISTORY

Do you have any significant illnesses?
Current medications?
Do you have any allergies for example to eggs, antibiotics?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you have epilepsy?
Do you have a history of mental illness?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant or planning pregnancy or breast feeding?
Please write below any further information which may be relevant

VACCINATION HISTORY

Have you ever had any of the following vaccinations/malaria tablets and if so when? Give approximate date if unsure.
Tetanus / Polio / Diphtheria
Typhoid / Hepatitis A / Hepatitis B
Meningitis / Yellow Fever / Influenza
Rabies / Jap B Enceph / Tick Bone
Other
Malaria Tablets Prescription Issued - Charge payable for Private Prescription of £17.00

For discussion when risk assessment is performed within your appointment, if required:

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

Signed:Date:

FOR PATIENT

PATIENT NAME: ______DATE OF BIRTH:

TRAVEL RISK ASSESMENT PERFORMED YES [ ] NO [ ]

APPOINTMENT REQUIREDYES [ ] NO [ ]

TRAVEL VACCINES RECOMMENDED FOR THIS TRIP

Disease Protection / Yes / In stock? / Patient to collect pres / Presc done / Script fee / Vac/admin fee / Total cost for patient
Hepatitis A / free
Hepatitis B / £17.00 / £10.00*
Typhoid / free
Cholera / £17.00 / £10.00*
Tetanus / free
Diphtheria / free
Polio / free
Meningitis ACWY / £17.00 / £10.00*
Yellow Fever**
Rabies x 3 / £17.00 / £10.00*
per dose
Japanese B Encephalitis x 3 / £17.00 / £10.00*
per dose
Tick Bourne
Encephalitis / £17.00 / £10.00
Malaria / £17.00 / free
TOTAL CHARGE TO PATIENT

* Not available on NHS prescription so charge will be made at the practice

**Please contact Aberdeen 01224 562747 or Montrose 01674 672554

CASH/CHEQUES ONLY MADE PAYABLE TO LAURENCEKIRK MEDICAL GROUP

APPROXIMATE PRICE TO DATE AT DECEMBER 2012:

ANTI MALARIALS:

Malarone tablets 12 @ £37.82

Doxycycline tablets 100mg – 100 @ £9.18

VACCINES:

Rabies 3 @ £129.60

Japanese B encephalitis - 1 @ £84.00

Hepatitis B 20mg - 1 @ £18.51

Tickbourne encephalitis - 1 @ £48.00

TRAVEL RECORD CARD SUPPLIED

MALARIA PREVENTION ADVICE AND MALARIA CHEMOPROPHYLAXIS[TO BE COMPETED BY NURSE]

State chemoprophylaxis recommended or write “none”

Available to buy OTCYes [ ]No [ ]

Prescription required Yes [ ]No [ ]

Prescription doneYes [ ]No [ ]

Start date for medication:End date:

SIGNED BY:POSITION:DATE: