Travel Vaccine Application Form

CULLYBACKEY HEALTH CENTRE

TRAVEL VACCINE APPLICATION FORM

Please complete this form and email to

or hand in to reception

Proposed itinerary:

Please list countries and exact areas to be visited within each country as this may be relevant to whether certain vaccines are required. If you are visiting more than 1 country, please give duration of stay within each country.

Women only:- are you pregnant/planning pregnancy/breastfeeding? Yes / No

If yes, please give details: ______

VACCINES

Information on specific countries regarding vaccinations is available at . Please access the destination you are travelling to, and carefully read the information regarding advice and vaccines required.

Each webpage outlines the vaccines usually advised for each destination and also vaccines to consider. The reasons to consider additional vaccines are detailed on this webpage, and links to further information on each disease is also available by clicking on the blue text relating to each disease.

There is also a link relating to a ‘Malaria Map’ on each country(if malaria is prevalent in that country) – please locate the destination you are travelling to, as not all areas within a country require malaria prophylaxis.

If you are visiting a destination within a rural environment, area of deprivation, a location remote from healthcare services or if you are working as a healthcare professional, you may require these additional vaccinations.

Please read this information, so you are fully informed as to the diseases and requirement for vaccines, and mark this box by typing an‘X’ to indicate you have read the advice on this website. [ ]

You will always require the vaccines that are usually given for each country. If you believe due to the nature of your trip you may require additional vaccinations, please indicate which vaccines you require:

[ ] Tetanus

[ ] Hepatitis A

[ ] Typhoid

[ ] Polio

[ ] Diptheria

[ ] Cholera

[ ] Hepatitis B

[ ] Tick Encephalitis

[ ] Rabies

[ ] Japanese Encephalitis

[ ] Meningitis

[ ] Anti-Malarials – if so for how many days will you be in an area requiring anti-malarial cover? ______

[ ] Yellow Fever

Depending on what vaccine you require, the practice may charge a fee, as some vaccines are not available under an NHS prescription, and the administration of the vaccine is not covered by the NHS.

The following vaccines are available without charge:

Tetanus

Hepatitis A

Typhoid

Polio

Diptheria

The following vaccines are not available under the NHS. A private prescription will be issued and a fee of £10 per item will be charged.

Hepatitis B course

Tick Encephalitis

Rabies course

Japanese Encephalitis

Meningitis

Anti-Malarial tablets

Chemists will charge for the cost of the items on the prescription plus a dispensing fee.

Yellow Fever

The practice is not a registered Yellow Fever Centre and therefore cannot prescribe or administer this vaccine

Please note:

• All travel scripts should be collected at the reception desk. If a fee applies then this is to be paid when collecting the script from reception. This fee should be paid by cash or cheque.

• Please give your script into the pharmacy but do NOT collect it until the day of your appointment.

• The Practice Nurse will phone or email you within 2 weeks of receipt of this form to confirm vaccinations and arrange a suitable appointment for administration of these.

• Ideally this form should be completed at least 3 months before departure, and no later than 3 weeks prior to travel, as vaccines take time to become effective.

Cullybackey Health Centre Travel Vaccination form Page1/3