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Heath Lane Surgery

Westfield Avenue, Earl Shilton, Leicester, LE9 7RT

Telephone: 01455 844431

We're open

Travel Vaccinations

If you are travelling abroad, please complete the travel form at least 8 weeks before you travel.

You can return the completed form by:

  • Handing it in at reception, or
  • Emailing it to heathlane.surgery@nhs.net

A member of the nursing team will review your form and contact you if you need an appointment for travel health advice or vaccinations.

Travel Risk Assessment

This field is for validation purposes and should be left unchanged.

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Name
Gender
Email
.
TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY
Are you fit and well today(Required)
Any allergies including food, latex, medication(Required)
Severe reaction to a vaccine before(Required)
Tendency to faint with injections(Required)
Any surgical operations in the past, including e.g. your spleen or thymus gland removed(Required)
Recent chemotherapy/radiotherapy/organ transplant(Required)
Anaemia(Required)
Bleeding /clotting disorders (including history of DVT)(Required)
Heart disease (e.g. angina, high blood pressure)(Required)
Disability(Required)
Diabetes(Required)
Epilepsy/seizures(Required)
Gastrointestinal (stomach) complaints(Required)
Liver and or kidney problems(Required)
HIV/AIDS(Required)
Immune system condition(Required)
Mental health issues (including anxiety, depression)(Required)
Neurological (nervous system) illness(Required)
Respiratory (lung) disease(Required)
Rheumatology (joint) conditions(Required)
Spleen problems(Required)
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Have you undergone FGM / been cut / circumcised
PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST
Tetanus/polio/diphtheria
Typhoid
Cholera
Rabies
Yellow fever
MMR
Hepatitis A
Hepatitis B
 
part 2
Hepatitis B
Japanese encephalitis
BCG
Influenza
Pneumococcal
Meningitis
Tick borne encephalitis
Malaria Tablets
Other
 
Signature(Required)

Travel Vaccination Assessment Form

When booking, please provide details of:

  • The countries you are visiting
  • The areas you will be travelling to
  • How long you will be away

This helps us decide which vaccinations or travel advice you may need.

Important Information

  • If your child has previously had a single dose of Hepatitis A vaccine for travel, they may need a booster dose for longer-lasting protection. Please contact the surgery to arrange an appointment.
  • If you are travelling for more than one month, visiting multiple countries, or travelling to remote areas, please contact us as early as possible. Some vaccine courses can take several months to complete.
  • Not all travel vaccines are available on the NHS. Some vaccines and medications may incur a charge. The nurse will advise you of any costs before treatment is given.
  • Some malaria medications are only available on a private prescription. A £9.00 private prescription fee applies, in addition to the cost of the medication.
  • We are no longer able to provide Yellow Fever vaccinations. Please visit a designated Yellow Fever vaccination centre for this service.

Please note: Last-minute holidays do not qualify for an emergency appointment, although we will do our best to help where possible.