This form should be completed and printed - do not send by email
Only necessary for "complicated" journeys or long
term stay abroad. For 1-2 week holidays, please talk to our reception
staff
TRAVEL VACCINE request form
Name:__________________________________________________
Date of Birth:____________________________________________EMAIL
address:___
I am travelling to: _______________________________________________
I am leaving UK on________________________
I am returning to UK on:________________________________
This is (please delete as appropriate)
I have read the information and checked the Fitness to Travel website
and believe that I should need the following vaccines/malaria
medications:
|
Please tick those
required |
|
For OFFICE use
|
| Typhoid |
|
Available on NHS for non-occupational travel |
|
| Hepatitis A |
|
Available on NHS for non-occupational travel |
|
| Hepatitis B |
|
Available on NHS for non-occupational travel |
|
| Rabies |
|
Only
available on private prescription unless Vet or working in
animal sanctuary |
|
| Japanese B
encephalitis |
|
Only
available on private prescription |
|
| Cholera |
|
Available on NHS for non-occupational travel |
|
| Meningitis ACWY |
|
Available on NHS for non-occupational travel |
|
|
Tetanus/Diphtheria/Polio |
|
Available on NHS for non-occupational travel |
|
| Other: |
|
|
|
For Malaria prevention, I would like: - please tick
Doxycycline (can make you sensitive to the sun)
Malarone (Atovaquone with proguanil hydrochloride)
I am in the malaria region for ________________days
Signed: ______________________________________ dated:____________
