Pre Travel Risk Assessment Form - Timber Hill Health Centre
Pre Travel Risk Assessment Form - Timber Hill Health Centre
Pre Travel Risk Assessment Form - Timber Hill Health Centre
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Name<br />
Contact details<br />
<strong>Timber</strong> <strong>Hill</strong> <strong>Health</strong> <strong>Centre</strong><br />
<strong>Travel</strong> risk assessment form<br />
To be completed by traveller prior to making appointment<br />
Date of<br />
Birth<br />
Telephone:<br />
Mobile:<br />
Date of Departure<br />
Date of Return<br />
<strong>Travel</strong>ling to<br />
Please give as much detail as possible including cruise reference<br />
numbers.<br />
Duration of stay in each<br />
destination<br />
Duration of trip<br />
If multiple destinations, please try to list countries visited in order<br />
Living conditions<br />
Type of trip<br />
Medical history<br />
Tent/ motorhome/ hostel/ hotel/ family home/ safari lodge/ other…<br />
Please circle: Package holiday/ cruise/ business/ organised adventure/<br />
backpacking/ voluntary or charity work/ visiting friends or relatives/<br />
elective/ other<br />
Very important to bring record of any vaccines ever had<br />
Current:<br />
<strong>Pre</strong>vious:<br />
Current medication (please<br />
list all, including the<br />
contraceptive pill and non<br />
prescription medicines)<br />
Allergies<br />
Any reaction to previous<br />
vaccines<br />
Yes or no and which if known<br />
Have you ever taken any<br />
anti-malarials and which<br />
Please post completed forms to: <strong>Timber</strong> <strong>Hill</strong> <strong>Travel</strong> Clinic, 115-117 Castle Mall, Norwich, NR1 3DD<br />
Please allow at least 48 hours before contacting us to make an appointment on 01603 611786<br />
PLEASE COMPLETE REVERSE
<strong>Timber</strong>hill runs a Private <strong>Travel</strong> Medicine Clinic, this is a non –NHS service.<br />
Any trip abroad you are planning should begin with a <strong>Risk</strong> <strong>Assessment</strong>. This may indicate that you<br />
require a number of vaccines or products to prevent illness while you are away. Your GP Practice or<br />
<strong>Travel</strong> Agent may have advised you to seek advice on vaccine requirements for your destination.<br />
When booking your <strong>Travel</strong> Medicine appointment at <strong>Timber</strong>hill you are booking an appointment<br />
for a private service and we ask you to pay a £20 non-refundable consultation fee, this is in line<br />
with other local travel medicine service providers. Our clinic staff have specialist qualifications in<br />
<strong>Travel</strong> Medicine and it is our aim to offer a comprehensive quality service. Should you not attend<br />
your appointment without letting us know you forfeit the consultation fee.<br />
Charges are made for any vaccines, products or services which you receive in the clinic in addition<br />
to the consultation fee.<br />
Vaccination costs are per dose (injection) the second column indicates where more than one dose<br />
is needed to complete a course.<br />
Cholera 2 30.00<br />
Hepatitis A 1 45.00<br />
Combined Hepatitis A and typhoid 1 75.00<br />
Combined Hepatitis A&B (Twinrix) price per dose 3 63.00<br />
Hepatitis B 3 45.00<br />
Influenza 1 9.50<br />
Japanese encephalitis (Ixiaro) 2 82.00<br />
Measles, Mumps, Rubella (MMR) (Under 25) 1 35.00<br />
Measles, Mumps, Rubella (MMR) (Over 25) 1 35.00<br />
Meningitis Polysaccharide vaccine ACWYVax 1 45.00<br />
Meningitis ACWY (Menveo) 1 75.00<br />
Pertussis (Whooping cough vaccine) 1 40.00<br />
Pneumovax 1 30.00<br />
Rabies 3 55.00<br />
Tick borne encephalitis 2 65.00<br />
Typhoid 1 35.00<br />
Yellow fever 1 60.00<br />
Children’s vaccines<br />
Ambirix (A&B under 16 years) 2 62.00<br />
Engerix B paediatric (under 16years) 3 25.00<br />
Hepatitis A -Havrix mono junior (ages 1-15years) 1 30.00<br />
Please be sure you understand these facts prior to booking an appointment. Please also ensure<br />
you have sufficient funds to pay for any vaccinations, products or services received at the time of<br />
appointment. Price list may be subject to change.<br />
I acknowledge and understand the terms and conditions of booking an appointment at <strong>Timber</strong>hill<br />
<strong>Travel</strong> Clinic<br />
Signed………………………………………………………………….. Date…………………<br />
NB If you are a registered patient of <strong>Timber</strong>hill and know that you require Yellow Fever, Rabies,<br />
Cholera, Malaria pills, Japanese encephalitis, Tick borne encephalitis or Meningitis vaccines<br />
please book an appointment in the <strong>Travel</strong> Clinic. The Practice Nurses are unable to assist with<br />
these vaccines.