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Travel Vaccination Form

We will need 2 months’ notice prior to your departure to enable us to deal with your request.

 We will contact you within 2 weeks of receipt of this form, and make an appointment as necessary.

 Please fill in a form for each person travelling.

  Please note that only some vaccinations are available on the NHS and will be administered free of charge. If other vaccines are required, there will be a £10 administration charge for each vaccine.

  There is a £10 charge for each prescription of anti-malarial treatment.

1Personal details

2Dates of Trip

3Itinerary

4Purpose of visit

5Personal medical history

6Declaration

7Patient information

The following vaccines are available on the NHS and will be administered free of charge:

Diptheria/Tetanus/Polio

Typhoid Hepatitis A

Any other vaccines not listed above may carry a private prescription cost (which is payable to the chemist) and a £10 administration charge for each vaccine (which is payable to the practice). There is a £10 charge for each prescription of anti-malaria treatment.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


Your Neighbourhood Professionals. Just a Click Away! Warrington Housing Association
5 Thelwall Lane, Latchford, Warrington , WA4 1LJ
  • Telephone 01925 637508
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Your Neighbourhood Professionals. Just a Click Away! Warrington Housing Association
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