Travel Risk Assessment Form

Please supply information about your trip in the sections below

Please supply details of your personal medical history

History of previous vaccinations

Please list all the tablets and medicines that you are presently taking regularly

You have a right to privacy under the General Data Protection Regulation 2016 (GDPR) and the Data Protection Act. The Practice needs your personal, sensitive and confidential data in order perform our statutory duties.

By signing this form you give the Practice permission to hold this information. Details of how we use your information are available in leaflet form from reception or our website.

Please note not all travel vaccines are available on the NHS

Cost of Non NHS Vaccine

YELLOW FEVER £60.00
RABIES  *** £58.00 PER VACCINATION
HEPATITIS B  *** £55.00 PER  VACCINATION
CHILD HEP B *** £28.00 PER  VACCINATION
MENINGITIS ACWY £70.00
CHOLERA *** £58.00
JAPANESE ENCEPHALITIS *** £88.00 PER  VACCINATION
MALARIA PRESCRIPTION £15.00 FAMILY(4) £45 EACH ADDITIONAL PERSON £8.00
DUPLICATE CERTIFICATES £20.00
TICK ENCEPHALITIS £63.00
EXEMPTION CERTIFICATES £20.00

PRIVATE TRAVEL

HEPATITIS A + B (CHILD) £46.00
HEPATITIS A + B ADULT *** £66.00
DIPHTHERIA / TETANUS / POLIO £32.00
HEP A ADULT £48.00
HEP A CHILD £48.00
TYPHOID £30.00
HEP A + TYPHOID £83.00

*** Vaccines are given as a course of 2 or more doses

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MK Village Practice