Travel Vaccinations

We offer some travel vaccinations free on the NHS; these are Hepatitis A, Typhoid, Cholera and Tetanus. Some other vaccinations may incur a charge.

For more information please use this link: Travel Vaccinations - NHS

If you are due to travel, please complete the online form below at least 10 weeks (preferably 10 to 12 weeks if possible) before you travel.

If you you prefer, you can download a copy of the form here: Travel assessment form (PDF, 193KB) Please hand the completed form into the surgery.

Travel vaccinations will only be given if there is Nurse capacity to do so. Once this is received the nurse will, if necessary, contact you to arrange an appointment to discuss your travel plans and provide the relevant vaccination(s).

For more travel advice see the National Travel Health Network and Malaria Hotspots.

Travel Vaccinations

There is currently a nationwide shortage of Hep A & Hep B

If you are going on a holiday which requires you to have vaccinations it is essential that you book your immunisations early. Some immunisations are ineffective if not given early enough and we do not have emergency appointments available for immunisations.

If you do not send the completed form to us at least 10 weeks (preferably 10 to 12 weeks) before travel we will not be able to immunise you and you may therefore need to attend a private clinic at a cost to you.

Thank you for your cooperation.

Private clinics are available at, but not limited to:

Woodhouse Medical Centre 0113 221 3533
Traveldoc 0113 3448699
Superdrug 0113 2340411

Appointment Details

Appointment datePlease provide in the format DD/MM/YYYY

Appointment timeHH:MM

Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

Your Travel Arrangements

What date are you leaving the UK?Please provide in the format DD/MM/YYYY

Is the trip holiday or work?

Destinations

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1

Country 1 Name

Which area are you staying in in country 1? (Please be exact)

Please give dates of your stay in country 1

Please give details of your accommodation in country 1 (hotel, private house, camping etc)

Country 2

Country 2 Name

Which area are you staying in in country 2? (Please be exact)

Please give dates of your stay in country 2

Please give details of your accommodation in country 2 (hotel, private house, camping etc)

Country 3

Country 3 Name

Which area are you staying in in country 3? (Please be exact)

Please give dates of your stay in country 3

Please give details of your accommodation in country 3 (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Tetanus

Have you ever had a tetanus immunisation?

Typhoid

Have you ever had a typhoid immunisation?

Cholera

Have you ever had a cholera immunisation?

Rabies

Have you ever had a rabies immunisation?

Hepatitis A

Have you ever had a hepatitis A immunisation?

Polio

Have you ever had a polio immunisation?

Meningitis

Have you ever had a meningitis immunisation?

Yellow Fever

Have you ever had a yellow fever immunisation?

Hepatitis B

Have you ever had a hepatitis B immunisation?

Diphtheria

Have you ever had a diptheria immunisation?

Please give details of any other vaccinations you have received

Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

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 and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Diamond Medical Group • Rutland Lodge Medical Practice, Scott Hall Road, Leeds, LS7 3DR.

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.