Travel Vaccination Form - Tudor Gate Surgery

✈️ If you are travelling abroad, you may need vaccinations.

Please complete this form so the clinical team can assess which vaccinations are appropriate for your trip.

Free travel vaccinations available on the NHS

The following travel vaccinations are available free of charge:

These vaccines are provided because they protect against diseases that pose a public health risk.

Important: Please allow sufficient time before travel for vaccinations to be arranged and administered.

Some travel vaccinations are not available on the NHS and must be arranged privately:

Yellow fever vaccinations are only available at designated centres.

Please complete and submit this form so your vaccination needs can be reviewed.

Some vaccinations may incur a charge.

You can check what vaccinations and health advice may apply to your destination before you travel.

Full Name

Address

Date Of Birth

Phone Number

Email Address

List Destinations - Country or Resort (Include any stopovers on the journey)

Date of Travel

Length of Stay

TYPE OF ACCOMMODATION (e.g. hotel, self catering, camping, backpacking, etc )

Are you pregnant or might you be before you travel?

Yes

Please list any known allergies

Please select which Travel Vaccines you need?

If 'other' please state what travel vaccinations you need