Midway

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Midway Surgery
93 Watford Road
St Albans
Hertfordshire
AL2 3JX

TELEPHONE: 01727 832125
EMERGENCIES: 01727 856511
OUT-OF-HOURS: 03000 333333

Travel Immunisation Online Form

All appointments for travel vaccinations with the nurse are non-urgent appointments and need to be booked well in advance. Vaccines such as Hepatitis B and Rabies require a course of 3 injections over a period of months. If you are travelling within 2 weeks, it may not be possible to offer you a suitable appointment and you may find it easier to get an appointment at one of the following private travel clinics: Herts Clinic 01727 898162, or Masta at Hemel Hempstead 01442 236733.

Applicant

First Name :

Surname :

Address :

Town :

County :

Postcode :

Home Telephone :

Mobile Telephone :

Email address :*

Confirm email :*

Travel Details?

Countries to be visited:

Date of departure:

For how long?:

Nature of trip (holiday, business, voluntary work):

Where will you be staying (e.g. hotel in resort, relatives in village, tent in countryside):

Are you planning any safaris, jungle exploration, travel in difficult terrain?

Yes No

Will you be travelling to sub-saharan Africa or South America?

Yes No

If your answer to either of the above questions are YES please contact MASTA (Medical Advisory Service for Travellers Abroad) on 0906 5501402 or visit www.masta.org . You will need to give details of itinerary. Calls cost £1 per minute. Masta will send comprehensive travel advice and immunisation requirements, which you will need to bring to your consultation. Alternatively you will need to attend a private travel health service.

VACCINATION HISTORY

(Please fill in if NOT given here at the Midway)

		Yes/No	Dates Given
In the last 10 years	Tetanus	Yes No
	Diptheria	Yes No
	Polio	Yes No
	Hepatitis A 1st	Yes No
	Hepatitis A booster	Yes No
	Yellow Fever	Yes No
In the last 3years	Typhoid	Yes No
	Meningitis (please specify A+C or ACWY)	Yes No
Have you ever had a course of any other vaccination?	Rabies / Hepatitis B etc.	Yes No

PLEASE NOTE: We do not provide Tick-Bone Encephalitis, Japanese Encephalitis and Rabies vaccines.

We stock the following vaccines: Hepatitis A, Typhoid, Tetanus with Diptheria and Polio, Hepatitis B, Meningitis ACWY and Yellow Fever.
However Yellow Fever, Meningitis ACWY and Hepatitis B are not available on the NHS and a fee is payable in advance for these vaccines.

Malaria tablets are not available on the NHS. Some (Proguanil and chloroquine) can be purchased at the chemist, although some areas have resistance and may and may require an alternative such as Mefloquine (Larium), Doxycycline or Malarone, which require a private prescription from the nurse at the time of your appointment.

Thank you for your co-operation

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