Holiday Vaccination Form

You can use this form to email the practice nurses about holiday vaccination requirements. Submit your details on this form. We are not able to contact you with the information. Please note that there might be some delay in being able to vaccinate patients in October and November due to flu vaccination programme. We will have a list of your repeat prescriptions. Please telephone the surgery (0191 2814777) FIVE working days after submitting this form. We are unable to tell you what you need unless you follow up this form by making contact with the surgery. If indicated, the receptionist will make an appointment for you to see the practice nurse. If the vaccine is not covered by the NHS, the receptionist will be able to give you an estimation of the likely cost. Some malaria prophylaxis is available over the counter from your chemist without a presciption, but more exotic places especially equatorial Africa and some areas in the Far East will require a private prescription from your doctor. The practice nurse will arrange for this prescription to be made available after your appointment with her.

Please complete all fields marked *

*First name: *Last name: *Date of birth: *Email: *Phone no: *Destination(s): Your address: Date of Holiday: Length of stay: Accommodation: hotel family/friends home camping backpacking hosteling self-catering Are you currently taking any regular medication? no yes If yes, please specify: Are you allergic to anything eg eggs, Penicillin, nuts,etc? no yes If yes, please specify: Have you ever had a reaction to any vaccinations? no yes If yes, please specify: Are you pregnant? no yes Are you having any cancer treatment? no yes Are you taking any steroids? no yes Are you HIV positive? no yes Have you been vaccinated against the following? Yellow fever: no yes Date:       Typhoid: no yes Date: Tetanus: no yes Date:       Polio: no yes Date: Meningitis: no yes Date:       Hepatitis A: no yes Date: Hepatitis B: no yes Date:       Cholera: no yes Date: Immunoglobulin: no yes Date:       Any other vaccine   Name: Date: