Travel Clinic Form

We would emphasise that you should seek specialist advice through a private travel clinic if you need to consider other vaccines (eg Hep B, Japanese Encephalitis or Yellow Fever) or if you need Malaria prevention tablets. These are not covered by the NHS.

Health risks abroad vary between countries. Your individual risk will depend on where you are going, how long you are travelling for, accommodation, your planned activities and your general health.

Some travel vaccines are available free of charge to NHS patients:

Diptheria, Tetanus, Polio boosters (lasts at least 10 years)
Typhoid (lasts 3 years)
Hepatitis A (lasts 1 year unless repeated within a year in which case can confer immunity for 20 years)
Cholera

Vaccinations at the surgery are carried out by the practice nurse.

To arrange to be vaccinated for travel:

Complete this Travel Clinic Form online or by calling to the surgery in person and collecting a copy of the form. If you are travelling as a family an individual form will be needed for each person.
Completed forms should be returned to the surgery at least 8 weeks before you plan to travel.
Once we have received your completed form, the practice nurse or pharmacist will review the information you have provided and be in touch to discuss which NHS vaccines you require and arrange an appointment for you. This will take up to one week. Please be sure to provide your correct contact number on the form.
You can access further travel advice from your local pharmacy, private travel clinics or online at www.fitfortravel.nhs.uk
We will be happy to provide you with a copy of your vaccination record.

Travel Clinic Form

Name *

Date of Birth *

Telephone number *

Date of travel *

Length of stay *

Travelling to *

Resort *

Accommodation Type (i.e. Hotel, Hostel) *

Will your stay involve travelling outside tourist areas *

Yes No

If Yes please provide more details i.e. Rural areas, paddy (rice) fields, remote areas

Is your travel for work purposes *

Yes No

If Yes please provide more details i.e. Healthcare, Farming etc

Will your stay involve staying in different areas *

If Yes please provide more details i.e. transportation and Regions (please state length of stay in each region)

The practice will only be able to provide advice and vaccines available on the NHS, and that I may still need to seek advice and vaccines from a private clinic if I need to consider other vaccines (e.g. Hep B, Japanese Encephalitis or Yellow Fever) or need Malaria prevention tablets as these are not covered by the NHS.

Please confirm that you understand and accept the above statement: *

I understand

I do not understand

The following section is for practice use only

If you are a patient please do not complete the following questions

Vaccines Required

Prescription Issued

Travel advice provided

Administered by:

Date

Patient Confirmation

Consent *

I consent to my information being used for the purposes described above and wish to submit this online form to Eden Park Medical Practice • 585 -587 Crumlin Road, Belfast, BT14 7GB

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Page last reviewed: 16 September 2025

Travel Clinic Form

Travel Clinic Form

Further Information