Reception: Travel Form

Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.

The practice offers travel advice and vaccines that are available free on the NHS. These are listed below:

  • Polio (given as the combined diphtheria/tenanus/polio)
  • Typhoid
  • Hepatitis A
  • Cholera

We DO NOT provide the following vaccines:

  • Hepatitis B
  • Japanese Encephalitis
  • Meningitis
  • Yellow Fever
  • Rabies
  • Tick-borne encephalitis
  • Tuberculosis (TB)

These vaccines can be obtained from a Travel Clinic. This service is offered by most large retail Pharmacies.

Once you have completed the form you will contacted by either text or a phone call. 

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.
Your Details
Your Travel Arrangements
Destinations
Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Further Information
Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


Local Services, Let
Local Services, Let