Download Tollgate Medical Travel Form - Frome Valley Medical Centre

Tollgate Medical Travel Form
Welcome to the Tollgate Travel Service, we provide a comprehensive service for all your travel needs. In
order to ensure appropriate advice and care is given please complete the attached form. The price list
below indicates the cost to you for immunisations but if you require further information please go to -
www.fitfortravel.nhs.uk
Before an appointment can be made a £40 (cash only) deposit must be taken for every individual
requiring an appointment. This deposit is refundable should you not need any chargeable vaccines.
Patients must call on the Thursday before the appointment to be informed of the cost of
vaccinations
Important Information
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We may not be able to give some vaccines if you have had some live vaccines or blood products
within the last few months please check with the nurse.
Pregnant & breast feeding women should avoid all live vaccines (MMR or Yellow fever, Oral
Cholera, Oral Typhoid)
If you have an illness (cough, cold, sore throat or other infection including a fever) you should
postpone the vaccinations until you feel better
Patients must call on Thursday before the appointment to be informed of the cost of vaccinations
Tollgate Price List (cash only)
Free to all NHS registered patients
Hepatitis A
Combined Hepatitis A & B (single Booster or initial course of 3- cost per injection)
Combined Hepatitis A & Typhoid
Typhoid
Diphtheria, Tetanus, Polio
Cholera Oral vaccine (oral course of 2 or 3, cost per pack)
Chargeable/ Private vaccines (cash only)
Administration charge (for the vaccines below only)
Hepatitis B (Course of 3 or 4, 1 month before travel - cost per injection)
Meningitis ACWY (Hajj or Umrah)**
Yellow Fever** (10 days before travelling) Not available until further notice
Rabies (Course of 3 - 1 month before travel, cost per injection)
Japanese Encephalitis (Course of 2-1 month before travel, cost per injection)
Tick-borne Encephalitis (Course of 3- 6 months before travel, cost per
injection)
Malaria Private Prescription - you will then need to buy the tablets from the
pharmacy
Immunisation certificate
Private prescription medication (per prescription, multiple items)
Free
Free
Free
Free
Free
Free
£40.00
£25.00
£35.00
£45.00
£70.00
£45.00
£15.00
£15.00
£15.00
** For some countries proof of vaccination is mandatory. In these cases immunisation certificates
are given at the time of vaccination, however, should you require a replacement you will be charged
£15.00.
Charges are based on guidelines given by the BMA and DOH.
PLEASE TEAR OFF THIS PAGE AND GIVE TO PATIENT
Tollgate Medical Centre Travel Form
Personal Details
Name
Date of Birth
Telephone No
Email
Dates of trip
Leaving and return dates
total number of days
Itinerary
Countries and Area to be visited
1.
2.
3.
Length of stay
How Remote? (i.e. more than 24hrs from a major city)
Type of Trip
Business
Package Holiday/ Resort
Visiting Family
Religious / Pilgrimage
Back packing/ Trekking
Charity work
Medical History- please details of any current medication or illness
List all chronic Medical conditions
List all allergies (Including Egg allergies)
Have you ever had a reaction to
medications or vaccines in the
past, if so what was it?
Have you recently suffered from an
infection (Fever symptoms, cold or
other infection)
Have you ever fainted after having
blood taken or receiving
injections?
List your current medications
Yes
No
Yes- Please make sure you are well
before having vaccines.
No
Yes- please inform the Nurse before
having your injections
No
Do you have any close family
Yes – Some antimalarial drugs may
members with epilepsy?
be unsuitable for you.
Do you have any Mental health
Yes – Some antimalarial drugs will be
Illness?
unsuitable for you.
Have you undergone
Yes
Chemotherapy, Radiotherapy or
steroid treatment if so when?
Are you Pregnant or planning a
Yes
pregnancy?
Have you taken out Travel insurance? Yes
Any other information?
No
No
No
No
No
Vaccination History- please give dates
Hepatitis A
Polio
Typhoid
Tetanus
Cholera
Diphtheria
Meningitis
Jap. Enceph
Any other vaccines?
Have you had any Malaria tablets in
the past, if so which ones?
Any problems or reactions to malaria
tablets?
Any preferences for this trip?
Hepatitis B
Rabies
Yellow fever
Tick bourn
Malaria Prevention Advice And Chemoprophylaxis
Weight in Kgs (Children only)
Length of time in Area (weeks or days)
Disclosure
The Tollgate Travel service is not a NHS service. We have a limited number of appointments and so
to ensure these are kept a deposit of £40 (cash only) per patient will be required.
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If you do not need any of the chargeable vaccinations your deposit will be returned to you.
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If you fail to attend your appointment, arrive more than 10 minutes after the start of your
appointment or cancel within 2 working days then the deposit will be lost.
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You may rebook after cancelling, arriving late or not arriving for your appointment but you
will be required to pay another deposit of £40 (cash only)
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It is your responsibility to book vaccinations in good time (2-6 weeks prior to travel). You
may still be able to have vaccines which may confer some protection but if you choose to
travel this is at your own risk.
Declaration
I have no reason to think that I might be pregnant. I have completed the above form to the best of my knowledge and
I consent to have vaccinations administered to me by the nurse/clinician.
Signed:
Relationship if not the patient
For Admin use only
NCV only (tick)
Emis No
Date of appointment
Initials
Date: