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Travel Questionnaire

Travel Questionnaire

 

Name-------------------------------------------------------------------------------------------------------------

Address----------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------

DOB---------------------------------------------Contact Tel No------------------------------------------------

Destination----------------------------------- Country--------------------------------------------------------

Region----------------------------------------- Date of Travel ------------------------------------------------

Duration of Trip--------------------------------------------------------------------------------------------------

Purpose of Trip:                     Business            Pleasure     Other

Type of Trip:                           Package            Self- Organised               Backpacking

                                                Camping           Cruise Ship                    Trekking

Accommodation:                     Hotel              Friends/ Family             Other

Travelling:                                Alone                 With Friend/Family         In a Group    

Location Type:                         Urban                 Rural

Activity Type:                            Safari                  Adventure         Exploration        Other

 

Allergies--------------------------------------------------------------------------------------------------------------

Previous Vaccinations (If Known) -----------------------------------------------------------------------------

Please complete this form and return it to reception.  The nurse will then decide which vaccines are required and will organise the relevant prescription.  Please telephone the surgery 72 hours later to arrange an appointment with the practice nurse.  Prescriptions must be collected prior to your nurse appointment.

A charge of £10 per private prescription will be made by the practice payable on collection of the prescription from reception.

 

 

TRAVEL VACCINATIONS

Anti-malarial treatment and some travel vaccinations are not provided by the NHS and a charge will be made by the practice for provision/administration of a private prescription for vaccinations.  You will also be required to pay the pharmacist for non NHS vaccines and anti-malarial drugs.

Available on NHS Prescription at no cost.

Hepatitis A

Typhoid

Polio

Diptheria

Tetanus

 

 

Not available on NHS

Private Presciption required

Cost made payable to pharmacy on collection

£10 private prescription fee made payable to practice______________

Rabies (Approx Cost £118)

Tick-BorneEncephalitis

(Approx Cost £45)

Hepatitis B (Approx Cost £20)

Meningitis (Approx Cost  £25)

 

Available only at Specialist Travel Clinic

Yellow Fever

Japanese Encephalitis

 

 

 

 

 

Specialist Travel clinics are:        Monklands Hospital . Tel No: 01236 712241

                                                                Gartnavel Hospital ,   Tel No : 0141 2110286

                                                                Glasgow Airport Travel Clinic :0141 884800               

                                               

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANTI-MALARIAL TREATMENT

 

Chloroquine :  Approx cost for  2 week holiday £5 Can Be purchased direct from the pharmacy

Proguanil :  Approx cost for 2 week holiday £14 can be purchased direct form pharmacy

Doxycycline :   Approx cost for 2 week holiday £11 Private prescription ONLY

Malarone:  Approx cost for 2week holiday £60 Private Prescription ONLY

(Anti Malaria drugs should be commences 1-2 days before entering endemic area, continued during stay until 1 week after leaving endemic area)

 

What is your preferred Anti Malaria drug-------------------------------------------------------------------------------

Please note that all drug prices will fluctuate.  This is only given as a guide

 

 

A charge of £10 per private prescription will be made by the practice payable on collection of the prescription from reception

 

 

                                                                                                                                                                                                                Please ensure that all vaccinations are complete 2-4 weeks before departure

               

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRAVEL VACCINATIONS

 

 

Name----------------------------------------------------------DOB ----------------------------------------

Destination------------------------------------------------------------------------------------------------

 

Recommended Vaccinations on NHS

 

----------------------------------------------------------

 

-----------------------------------------------------------

 

-----------------------------------------------------

 

Recommended Vaccinations Private                                                           Cost

 

-----------------------------------------------------         ----------------------------------------------------

-----------------------------------------------------         -----------------------------------------------------

-----------------------------------------------------         -----------------------------------------------------

 -----------------------------------------------------        -----------------------------------------------------

 

Total Cost:  £

 

 

 
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