Dr J M Bland (Partner)
Dr D M Carr (Partner)
Dr W A D Davies (Partner)
Dr L Jones
Dr H Seddon
Practice Manager: Lucy Evans / / The Crown Surgery
23 High Street
Eccleshall
Stafford
ST21 6BW

Dear Sir or Madam

RE: Travel Vaccination Request

You have recently requested an appointment with the practice nurse to discuss your requirements for travel vaccinations. In order to provide you with the appropriate protection during your trip we are required to complete a full travel risk assessment.

Please complete the attached form (one form per traveller) at least 6 weeks before your date of first travel to ensure that there is enough time to have all your vaccinations and we can order them in to stock. Pleaseensure all sections of the form are complete and return it to the surgery as soon as possible. Once you have completed and submitted the form please book a travel clinic appointment (one appointment per traveller) with one of our Practice Nurses.

In order to offer you a safe and complete service we are not able to see patients without first having the opportunity to review the full information provided on this form. Your appointment with the practice nurse will not be arranged until we have processed the information you have provided.Therefore, we require at least 1 week to process your risk assessment, and offer you an appointment.

The NHS provide some travel vaccinations and medication free of charge,dependent upon the circumstances of the particular trip that you are undertaking. However, it may be necessary to charge for certain vaccinations or medication, details are attached at the back of the Travel Risk Assessment Form (please note charges do change from time to time). You will be expected to make payment for all chargeable treatment prior to your appointment in order for us to order in the required medication, payment can be made by Cash or Cheque only, made payable to The Crown Surgery.

We have enclosed a travel advice sheet which you may find helpful. Children under 16 years old, who are attending without a parent or guardian,will need to ensure that the form is completed with the appropriate authorisation.

Should these arrangements not meet your requirements private travel clinicsare available. We are aware of the following organisations, however we have no experience of the services they offer;

Tesco Stafford
Newport Rd
Stafford
ST16 2HE
Tel: 01785 791410 / Boots Stafford
Market Square
Stafford
Tel: 01785 254082

Yours Sincerely

Drs Bland, Carr and Davies

THE CROWN SURGERY – TRAVEL RISK ASSESSMENT FORM

  • Please ensure that you complete this travel health assessment form at least 6 weeks before your date of first travel. We are unable to offer treatment and appointments at short notice.
  • ALL sections of the form must be completed in full.
  • One form must be completed by each traveler prior to your appointment.

PERSONAL DETAILS

Name: / Date of birth:
Male ( ) Female ( )
Daytime telephone number:
Mobile telephone number:

DATES OF TRIP

Date of departure:
Overall length of trip (Days):
ITINERARY AND PURPOSE OF VISIT
Country to be visited / EXACT location or region / City or rural / Length of stay
1.
2.
3.
TYPE OF TRAVEL AND PURPOSE OF TRIP – PLEASE TICK ALL THAT APPLY
Holiday Staying in hotel Backpacking
 Business Trip Cruise Ship Trip Camping / hostels
 Expatriate Safari Adventure
 Volunteer Work Pilgrimage Diving
 Healthcare Worker Medical tourismvisiting family / friends
Additional Information:
PLEASE SUPPLY DETAILS OF YOUR PERSONAL MEDICAL HISTORY
YES / NO / Details
Any allergies including food (eggs, nuts), latex, medication
Severe reaction to vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or thymus gland removed
Recent chemotherapy / radiotherapy / organ transplant
Anaemia
Bleeding/clotting disorders (including history of DVT)
YES / NO / Details
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and/or kidney problems
HIV/Aids
Immune system condition
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) disease
Spleen problems
Any other conditions
Women only:
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
Please supply information on any vaccines or malaria tablets taken in the past
Tetanus/polio/diphtheria / MMR / Influenza
Typhoid / Hepatitis A / Pneumococcal
Cholera / Hepatitis B / Meningitis
Rabies / Japanese Encephalitis / Tick Borne Encephalitis
Yellow fever / BCG / Other
Malaria Tablets
Any additional information (continue on separate sheet if necessary):

Signed …………………………………………………………………………….. Date: …………………………

I confirm that the information I have provided is accurate

Charges

We offer the travel health service free of charge, but unfortunately the NHS does not cover the cost of all the treatments you may need. Therefore, for some services you may need to pay, as detailed below;

All patients, including children will need to pay in advance for the following vaccinations for travel:

Hepatitis B

Adult single dose£ 60.00

Adult full course£120.00

Child single dose£ 16.44

Child full course£ 49.32

Meningitis ACWY£ 57.00

Rabies (3 injections)£176.25

Malaria - the price varies depending on the anti-malaria required, there will also be a prescription charge for the medication.

The following injections are available free of charge;

Hepatitis A

Typhoid

Combined Polio/Diphtheria/Tetanus

Payments will be confirmed by the Practice Nurse and can be made by cash or chequeat reception.

FOR OFFICIAL USE
Patient Name:
Travel risk assessment performed: Yes ( ) No ( ) Signed ………………………………………….
TRAVEL VACCINES RECOMMENDED FOR THIS TRIP
Disease protection / Yes / No / Date 1 / Date 2 / Date 3
Hepatitis A
Hepatitis B
Typhoid
Cholera
Tetanus
Diphtheria
Polio
Meningitis ACWY
Yellow Fever
Rabies
Japanese B Encephalitis
Other
MALARIA PREVENTION ADVICE AND MALARIA CHEMOPROPHYLAXIS
Chloroquine and proguanil / Atovaquone + proguanil (Malarone)
Chloroquine / Mefloquine
Doxycycline / Malaria advice leaflet given
ANY OTHER INFORMATION
e.g. weight of child

This declaration will be discussed at your appointment and your signature will be required.

I have no reason to think 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 vaccines being given.

Signed: ______Date: ______

Consent of Parent or Guardian may be required for children under 16 years of age

I confirm that the patient’s childhood immunisations are up to date

I give consent to the vaccinations being given

Signed by ______Date ______

Please provide full name ______

Parent / Guardian of ______

TRAVEL VACCINE PAYMENT FORM

As you are aware, the travel vaccines detailed below are not provided free on the NHS. At your Travel Consultation with the Practice Nurse, she has indicated below what you have been recommended.

Please take this form with you to Reception and make payment for all chargeable treatment prior to your immunisation appointment in order for us to order in the required medication. Payment can be made by Cash or Cheque only, made payable to The Crown Surgery.

PATIENT NAME:
PATIENT DATE OF BIRTH:
PATIENT ADDRESS:
VACCINATIONS / Recommended for travel? / Cost (£) / Amount Paid / Date Paid / Received by
Hepatitis B - Adult single dose / 60.00
Hepatitis B - Adult full course / 120.00
Hepatitis B – Child single dose / 16.44
Hepatitis B – Child full course / 49.32
Meningitis ACWY / 57.00
Rabies (3 injections) / 176.25
Malaria (please detail anti-malaria prescribed)
Other Vaccinations (please list)
TOTAL PAID