Test Page MALMESBURY PRIMARY CARE CENTRE TRAVEL SCHEDULE MALMESBURY PRIMARY CARE CENTRE TRAVEL SCHEDULE Name * Date of Birth * Telephone Contact Number * Your Address * Travel Itinerary * Date of Departure Length of Stay Destinations and any Stopovers * Type of travel – holiday, business etc * Accommodation – hotel, camping etc * Please allow 48 hours for completion of this form and then ring 825825 for recommendations and to book your appointments or call in at reception. – Payment for vaccines must be made before starting any vaccination course. – Payments can be made by cash, cheque or card (not American Express). – This form is to assist you in making a decision about travel vaccines for your trip. However, it is your responsibility to make any appointments with the Practice Nurse and for completion of any vaccination course. – Please inform nurse of any health conditions or if you are pregnant. Travel Clinic Fees – Initial Consultation and general advice and Typhoid, polio, diphtheria, tetanus and Hep A vaccination (Patients only) £Nil – Hepatitis B (£ 35 each) or for a course of 3 £105 – Yellow fever and certificate £65 Travel information, recommended vaccines and risk area for Malaria and other travel advice can be found on http://www.fitfortravel.nhs.uk/home.aspx or http://travelhealthpro.org.uk/ If you are human, leave this field blank. Submit