SONNING COMMON HEALTH CENTRE

TRAVEL IMMUNISATIONS FORM
VACCINATIONS REQUIRED FOR TRAVELLING ABROAD

N.B. please complete a separate form for each person travelling

*Compulsory Fields
*Name:
*Address:
*Tel no
*E-mail:
*Date of birth:
(dd/mm/yyyy)
 

*Countries to be visited (exact dates and regions within the country please, as this may affect the vaccinations required

Reason (specify): 
Work, holiday, backpacking, trekking

from

to
     
     
     
     
     
 

 
*Will you be away from medical aid for more than 24 hours? yes no

You can visit the Travax website on www.fitfortravel.scot.nhs.uk for the latest information

Any additional information as regards e.g. your destinations, please enter below
 

 

 

 

Please note that there is a professional fee for some immunizations which is payable before the injection is given. Payment can be made by cash, cheque or credit/debit card (we do not accept American Express).


Please indicate which of the following are required:

 required not sure nurse check fee
TETANUS      No charge
POLIO     No charge
DIPTHERIA     No charge
TYPHOID     No charge
HEPATITIS A*     No charge
YELLOW FEVER**      
HEPATITIS B**      
MENINGITIS MCWY**      
RABIES**      
CHOLERA**
(oral vaccine)		      

* Primary dose effective for 1 year with a booster at 6 months provides cover for 20 years. Not usually required by children (aged 6 and under) for holiday purposes.

** Yellow fever: certification required for some African and South American
                           countries
     Hepatitis B: not normally required for short holidays

Payment to be made prior to vaccination by cash or cheque.


To be advised at time of vaccination:

Malaria prophylaxis

Over-the-counter medication.
Available from our dispensary or from the chemist

   Mefloquine Malarone Doxycycline

 

Please call reception 2-3 days after sending the form 
to check on your vaccination requirements 
and make an appointment to see the nurse.

 

 
               

© 2008 Sonning Common Health Centre