Marsden Medical Group 

Travel Vaccination and Advice Form

Our Practice Nurses provide an immunisation and advice service for those travelling overseas. This service aims to make sure that you have up-to-date immunisation and advice, if needed, on medication necessary to prevent Malaria. Some important points to remember:

•	Some Travel Vaccinations and all tablets to prevent Malaria and other diseases whilst you are travelling are not covered by your registered GP practice under NHS rules. There is a charge for many Travel Vaccinations, which is payable at the time of vaccination. Chemists supplying Anti-malarial tablets will charge you the retail cost. You can choose not to have recommended vaccinations or to take anti-malarial tablets, but you must understand you are responsible for any increased risk.

•	You need to start planning your medical arrangements for travel as soon as possible. Immunisations are usually given 4 weeks prior to travel, and anti-malarial tablets (depending on which medication) started 2-16 days before entering malaria-risk areas. If you ask for immunisations less than 4 weeks prior to travel, we may be unable to arrange this at short notice and the vaccines are likely to be less effective.

•	Most illnesses which people get on holiday are not prevented by immunisations. Drinking safe water, avoiding over exposure to the sun and insect bites are all important.  

•	Make sure you have your Global Health Insurance Card and adequate Medical Insurance wherever you go. If you have any significant medical problems, make sure your insurers know before you travel. If you need a “fit to travel” certificate, or any kind of claim or cancellation form completed you will need to see a GP, and there will be a charge.

•	Make sure you have an adequate supply of any regular medication you take. If you are going away for more than 3 months, you will need to get further medication from a doctor in the area where you are travelling, as we are not allowed to prescribe more than 3 months medication.

•	Flights, or journeys by road longer than 4 hours, may increase your risk of developing a blood clot in your legs (known as a DVT or Deep Venous Thrombosis). This is especially true if you are pregnant, on the pill or HRT, have cancer or have had recent surgery, or have had DVTs or Pulmonary Embolism in the past. To reduce the risk, drink plenty of fluids, avoid alcohol and get up and stretch your legs. Consider getting support (“compression”) stockings over the counter from a chemist. Whether aspirin prevents flight-related DVTs is not clear. If you have had a previous blood clot, and are not taking Warfarin, please discuss this with your GP. 

•	If you become ill whilst you are away, especially with a fever, do not delay, seek medical help locally. The local Doctors will be far more expert at treating local health problems than we are, and delay in treating some illnesses, especially Malaria and DVT, can be fatal.

Anti-Malaria Tablets These, along with insect bite avoidance, are vitally important in Malaria-risk areas. There are four different types. Which is recommended depends on where you are going. If you are a child, or pregnant or breast-feeding, this may affect the drug recommended. Finish the full course of tablets (take for 4 weeks after leaving the malaria-risk area, or one week for Malarone). If you lose them or they are stolen, get replacements. Insecticide-treated anti-mosquito nets may be useful.

Chlorquine and Proguanil - Available over the counter from a chemist without prescription. 

Mefloquine (“Lariam”) -You need to see the nurse or GP if you want a prescription for these. 

Malarone -a drug started only 2 days before entering the risk area. The Practice nurse or your GP can give you a “private prescription” for this.

Doxycycline - For those over 12 years old. On private prescription from Nurse or GP.

Travel Vaccination Form

1.	Complete one form for each person who is travelling. 
2.	Hand it to the receptionists.
3.	Contact the surgery 2 or more working days later, and you will be told what vaccines are recommended and the cost. You can then make an appointment in our Practice Nurses’ travel clinic.
4.	Have the appropriate payment when you attend. No payment, no Injections!
5.	If you are not registered at Marsden Medical Group you will have to pay a £20 consultation fee when handing in the form, this is to allow the nurse to assess your needs, if you need to have the vaccines and choose to have them from our practice the £20 fee will be deducted from the final cost.

Name:

	D.O.B.	Age	
Address

	Contact phone number.	

YES	NO 
Please provide GP Details:

	
Are you registered at Marsden Medical Group?

What country are you visiting?

____________________________________________________________

On what date will you leave? 

____________________________________________________________

How long will you be away for? 

____________________________________________________________

How do you intend to travel? (air, rail, road, backpacking, etc.)  

____________________________________________________________

What is the purpose of your trip? (Holiday, business, visiting relatives) 

____________________________________________________________

What type of accommodation will you use? 

____________________________________________________________

What activities will you take part in? (Beach, safari, winter sports, climbing etc) 

____________________________________________________________

Are you currently in good health?
 
____________________________________________________________

Have you had any serious illness in the past?  If so, please give details:

____________________________________________________________

Do you have any recurrent or regular medical problems e.g. asthma, diabetes, epilepsy etc.  If so, please give details 

____________________________________________________________

Are you taking any regular medication?  If so, please give details 

____________________________________________________________

Are you allergic to any medicines?  Is so, please give details 

____________________________________________________________

Have you reacted badly to any previous vaccines?  If so, please give details 

____________________________________________________________

Are you taking steroid medication or any other drug that may affect the body’s immune system e.g. treatment for arthritis, cancer or following transplant surgery

____________________________________________________________

Are you pregnant or breast feeding? 

____________________________________________________________

I confirm the above answers to be correct to the best of my knowledge and request immunisation as appropriate to my trip, together with advice on anti-malaria drugs.  I agree to pay the cost of vaccines given to me. 

Patient’s signature (Parent if under 16 years) ____________________________________________________________

Date ____________________________________________________________

*Please bring any record of previous vaccinations with you.*	

Vaccination	Cost per Dose
MRHC (NHS)	Cost per Dose
PRIVATE	Last had	? needed	Paid (please initial)	
Diphtheria,
Tetanus & Polio (combined)	Nil	£40				
Hepatitis A
(single)	Nil	£60				
Typhoid
(single)	Nil	£45				
Hepatitis B*
	Nil	£55				
Nimenrix
(Meningococcal)	£70	£70				
Rabies*
	£90	£90				
Yellow fever	Not available here 	
X	
X	
X	
X	
Japanese B
Encephalitis*	£120	£120				
Tick Born 
Encephalitis*	£120	£120				
Private Prescription	£20 Per
 Prescription	£20 Per Prescription				
The estimated total cost to you of Vaccinations recommended by our travel clinic will be:			
Recommended anti-malarial option include:		
Patient NOT having any vaccines following assessment.		

Authorising Doctors Name		
Signature		
Date		

*PLEASE NOTE: PAYMENT IS REQUIRED BEFORE THESE CAN BE ORDERED*