Dr C. Doran Dr. M. Burrows
Dr K. Cubitt  Dr C. Mulholland  Dr. A.Carson

Notting Hill Medical Practice provides only NHS funded travel vaccinations and advice.

The vaccines which are available, for travel purposes, free of charge on the NHS are listed below:

•	cholera
•	hepatitis A
•	paratyphoid
•	poliomyelitis
•	smallpox
•	typhoid
•	tetanus

Travel vaccinations available on the NHS do not incur any additional charge from the travel clinic. 

Depending on your destination and planned activities you may need vaccines outside of the NHS service.  If this is the case you will need to attend a private travel clinic.

Private Travel vaccinations, which are not available on the NHS include but are not limited to:

•	Anti Malarials
•	Hepatitis B
•	Japanese Encephalitis
•	Meningitis ACWY
•	Rabies
•	Tick- Borne Encephalitis
•	Yellow Fever

Please note travel vaccinations and advice may take 4-6 weeks so please give ample time prior to your departure. Due to the pressure on our services we unfortunately cannot provide travel services with less than 2 weeks notice.

  	
Travel Assessment Form	
Personal Details	
Name:	
Date of Birth:	Male 		Female		
Easiest contact telephone number:	
Dates of Trip	
Date of departure:	
Return date or overall length of trip:	
Itinerary and purpose of visit	
	Country to be visited	Length of Stay	Away from medical help at destination?
If so, how remote?	
1				
2				
3				
Please circle the descriptions that best describe your trip	
1	Type of trip:	Business	Pleasure	Other	
2	Holiday type:	Package	Camping	Self-organised	 Cruise ship	Backpacking	  Trekking	
3	Accommodation:	Hotel	Relatives/family home	Other	
4	Travelling:	Alone	With family/friend	In a group	
5	Staying in area which is:	Urban	Rural	Altitude	
6	Planned Activities:	Safari	Adventure	Other	
	
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?	
	
Women only: Are you pregnant or planning pregnancy or breast feeding?	
	
Do you have any allergies or have you had a serious reaction to a vaccine in the past?	
	
Are you on any medication over the counter which the GP would not be aware of?	

	
Vaccination history	
Have you ever had any vaccinations at another surgery or private travel clinic? If so please list name and dates below:	

	

Travel vaccines recommended for this trip	
Disease Protection	Yes 	No	Further Information	
Hepatitis A				
Typhoid				
Cholera				
Tetanus				
Diphtheria				
Polio				
Other				
Private travel clinic advised