Microsoft word - vaccination registration form_pw with logo.doc
richmond practice vaccination registration form
Please complete this confidential registration form prior to your first consultation. Thank you.
your details
Address: ………………………………………………
Surname: …………………………………. ……………………………………………………….
First Name: ………………………………………………… ……………………………………………………….
Date of birth: ……. / ……. /…….
Post code: …………………………………………….
Marital status: ………………………………………………
Telephone: ……………………………………………
Occupation: ………………………………………………… Mobile: ……………………………………………….
Employer: …………………………………………………. Email: …………………………………………………
no Nationality: …………………………….
If so, who is your insurer? …………………………….
do you have a NHS GP?
GP name: ………………………………………. Address: ……………………………………………….
GP telephone number: ……………………………………. Post code: ……………………………………………. Do you want us to let your NHS GP know about the treatment you will receive?
where did you hear about us?
Website, which? ………………………………….
Pharmacy or Clinic, which? ………………………….
Doctor’s surgery, which? ……………………………….
Advertisement, which? ………………………….
Embassy, which? …………………………………
Other, please specify: ………………….
1Do you want to receive information about other services we provide? yes no
1 Records are kept in accordance with the Data Protection Act (1998) and contact details and information will usually not be passed on, without your knowledge.
dates of trip Date of departure: …………………………….
Return date or length of trip: …………………….
itinerary and purpose of visit
Away from medical help at destination, if so, how remote?
Please tick as appropriate below, to best describe your trip:
personal medical history
Do you have any recent or past medical history of note, including diabetes or a heart or lung
condition? …………………………………………………………………………………………………….
Do you or any close family members suffer with epilepsy? …………………………………………….
Do you have any history of mental illness including depression or anxiety? …………………………
Do you have any allergies, such as being allergic to eggs, antibiotics or nuts? .………………….
Have you ever had a serious reaction to a vaccine? ……………………………………………………
Does having an injection make you feel faint? ………………………………………………………….
Have you recently undergone radiotherapy, chemotherapy or steroid treatment? ………………….
Please write below any further information which may be relevant: ………………………………….
…………………………………………………………………………………………………….
women only: Are you? vaccination history
Have you had any of the following vaccinations/malaria tablets and if so when?
To the best of my knowledge the information in this registration form is correct.
Name: ………………………………………………………
signature: consent Consent to treatment is sought after a risk assessment is performed within your appointment.
I have received information on the risks and benefits of the vaccines recommended and have had
the opportunity to ask questions. I consent to the vaccines being given.
other comments:.
………………………………………………………………………………………………
signature: for official use: travel vaccines recommended for this trip malaria prevention advice and malaria chemoprophulaxis travel advice and leaflet given
Website(s) recommended………………………………………………………………………………….
Travel record card supplied: ……………………………………………………………………………….
Package leaflet: Information for the user Brevoxyl 4% Cream Read all of this leaflet carefully because it contains important information for you. This medicine is available without prescription. However, you still need to use Brevoxyl carefully to get the best results from it. - Keep this leaflet. You may need to read it again. Ask your pharmacist if you need more i
Uno studio interessante a proposito della equivalenza terapeutica tra farmaci generici e farmaci di marca; gli Autori che dichiarano la loro assenza di conflitti di interesse, ( Dr. Kaplan and Dr. McVary have disclosed no relevant financial relationships) fanno notare come in questo studio l'utilizzo dei generici rispetto ai farmaci di marca abbia portato ad un incremento dei valori di PSA, che a
richmond practice