Pre Travel Risk Assessment Form - Timber Hill Health Centre

Name
Contact details
Timber Hill Health Centre
Travel risk assessment form
To be completed by traveller prior to making appointment
Date of
Birth
Telephone:
Mobile:
Date of Departure
Date of Return
Travelling to
Please give as much detail as possible including cruise reference
numbers.
Duration of stay in each
destination
Duration of trip
If multiple destinations, please try to list countries visited in order
Living conditions
Type of trip
Medical history
Tent/ motorhome/ hostel/ hotel/ family home/ safari lodge/ other…
Please circle: Package holiday/ cruise/ business/ organised adventure/
backpacking/ voluntary or charity work/ visiting friends or relatives/
elective/ other
Very important to bring record of any vaccines ever had
Current:
Previous:
Current medication (please
list all, including the
contraceptive pill and non
prescription medicines)
Allergies
Any reaction to previous
vaccines
Yes or no and which if known
Have you ever taken any
anti-malarials and which
Please post completed forms to: Timber Hill Travel Clinic, 115-117 Castle Mall, Norwich, NR1 3DD
Please allow at least 48 hours before contacting us to make an appointment on 01603 611786
PLEASE COMPLETE REVERSE

Timberhill runs a Private Travel Medicine Clinic, this is a non –NHS service.
Any trip abroad you are planning should begin with a Risk Assessment. This may indicate that you
require a number of vaccines or products to prevent illness while you are away. Your GP Practice or
Travel Agent may have advised you to seek advice on vaccine requirements for your destination.
When booking your Travel Medicine appointment at Timberhill you are booking an appointment
for a private service and we ask you to pay a £20 non-refundable consultation fee, this is in line
with other local travel medicine service providers. Our clinic staff have specialist qualifications in
Travel Medicine and it is our aim to offer a comprehensive quality service. Should you not attend
your appointment without letting us know you forfeit the consultation fee.
Charges are made for any vaccines, products or services which you receive in the clinic in addition
to the consultation fee.
Vaccination costs are per dose (injection) the second column indicates where more than one dose
is needed to complete a course.
Cholera 2 30.00
Hepatitis A 1 45.00
Combined Hepatitis A and typhoid 1 75.00
Combined Hepatitis A&B (Twinrix) price per dose 3 63.00
Hepatitis B 3 45.00
Influenza 1 9.50
Japanese encephalitis (Ixiaro) 2 82.00
Measles, Mumps, Rubella (MMR) (Under 25) 1 35.00
Measles, Mumps, Rubella (MMR) (Over 25) 1 35.00
Meningitis Polysaccharide vaccine ACWYVax 1 45.00
Meningitis ACWY (Menveo) 1 75.00
Pertussis (Whooping cough vaccine) 1 40.00
Pneumovax 1 30.00
Rabies 3 55.00
Tick borne encephalitis 2 65.00
Typhoid 1 35.00
Yellow fever 1 60.00
Children’s vaccines
Ambirix (A&B under 16 years) 2 62.00
Engerix B paediatric (under 16years) 3 25.00
Hepatitis A -Havrix mono junior (ages 1-15years) 1 30.00
Please be sure you understand these facts prior to booking an appointment. Please also ensure
you have sufficient funds to pay for any vaccinations, products or services received at the time of
appointment. Price list may be subject to change.
I acknowledge and understand the terms and conditions of booking an appointment at Timberhill
Travel Clinic
Signed………………………………………………………………….. Date…………………
NB If you are a registered patient of Timberhill and know that you require Yellow Fever, Rabies,
Cholera, Malaria pills, Japanese encephalitis, Tick borne encephalitis or Meningitis vaccines
please book an appointment in the Travel Clinic. The Practice Nurses are unable to assist with
these vaccines.