Derby Medical Centre Travel Schedule & PSD

Derby Medical Centre Travel Schedule & PSD

Date: / Name: / Date of birth:
Address (for unregistered patients) GP
Contact telephone numbers:
Home Work Mobile
Destination(s) Country and area :

Travel Conditions e.g. Backpacking, Hotel?

Departure date: /

Length of visit:

FEMALES ONLY:

Are you pregnant, breast feeding or planning a pregnancy in the near future? YES / NO

Useful websites: www.fitfortravel.scot.nhs.uk

www.nathnac.org/travel/index.htm
www.fco.gov.uk/travel/
Travellers Signature (if completing form in person):
Reception Signature (if completed by telephone):

REGISTERED PATIENTS – One of our reception team will contact you about vaccines and appointments and any charges that may be due – please allow 7 to 10 days once the form has been completed.

You can email this form to our reception team

SECTION BELOW OFFICE USE ONLY

Recommended

/ Previous / 1st Appt / Notes
Hep A

Typhoid

Diptheria/Tetanus/Polio
Hep B
Rabies
Yellow Fever
Meningitis ACWY
Tick-borne Enceph
Jap B Enceph
Cholera
MALARIA
Atovaquone / Proguanil , Doxycycline, Mefloquine, Chloroquine, Proguanil
Bite avoidance only
No risk
Authorisation for a Patient Specific Direction (PSD)
Following the completion of a travel risk assessment using guidance from Travax, Nathnac and/or the ‘Green Book’, the vaccines named overleaf may be administered and antimalarial medication supplied under this PSD.
Signature of Doctor Date

Continued over ……….

Name, form & strength of medicine
(generic/brand name as appropriate) / Dose, schedule and route of
administration / Start & finish dates
Hepatitis A adult Avaxim 0.5ml / 1 dose
Hepatitis A junior (age 1 – 15 yrs) Vaqta Paediatric 0.5ml / 1 dose
Hepatitis B standard adult HBVAXPRO 10mcg 1ml / 3 doses at 0, 1, 6 months
Hepatitis B accelerated adult HBVAXPRO 10mcg 1ml / 4 doses at 0, 1, 2 and 12 months
Hepatitis B accelerated Engerix B 20 mcg 1ml / 4 doses at 0, 7, 21 days and 12 months
Hepatitis B junior standard HBVAXPRO 5mcg 0.5ml / 3 doses at 0, 1, 6 months
Hepatitis B junior accelerated HBVAXPRO 5mcg / 4 doses at 0, 1, 2 and 12 months
Hepatitis B junior Engerix B 20mcg (age 11 – 15 yrs) / 2 doses at 0 & 6 – 12 months
Hepatitis A & Typhoid Viatim (age 16 yrs +) / 1 dose
Twinrix / Hepatitis A & B adult / 3 doses at 0, 1, 6 months
Twinrix / Hepatitis A & B adult accelerated / 4 doses at 0, 7, 21 days and 12 months
Hepatitis A & B junior Twinrix / 3 doses at 0, 1, 6 months
Hepatitis A & B junior Ambirix (age 1 – 15 yrs) / 2 doses at 0 & 6 – 12 months
Typhoid polysaccharide injectable Typhim Vi or Typherix (age 2 yrs +) / 1 dose
Vivotif / Typhoid oral (age 6 yrs +) / 3 capsules taken every other day
Revaxis / Tetanus, Diphtheria, Polio (age 10yrs +) / 1 dose
Repevax / Tetanus, Diphtheria, Polio, Pertussis / 1 dose
Rabies Rabipur 1ml / 3 doses at 0, 7, 21-28 days
Rabies Vaccine BP (SPMSD) 0.5ml / 3 doses at 0, 7, 21-28 days
Rabies (Verorab) / 3 doses at 0, 7, (21) 28 days
Yellow fever / Stamaril (age 9 months +) / 1 dose
Vaccine and medication details recorded on patient computer record ( name, batch no, Stage, Site, etc.) / Y / N
Pts Own Vaccine record supplied or updated / Y / N
Travel risk management consultation performed by: (sign name and date)

DMC Travel Clinic/Travel Schedule and PSD Combined MS 2016