COMPLETE GREEN SECTION BELOW SAVE AND UPLOAD* TO STUDENT HEALTH VIA LINK* BELOW
Name: Click or tap here to enter text. Dob: Click or tap to enter a date. Tel. no. Click or tap here to enter text.
YOUR MEDICAL DETAILS: Enter details of Travel vaccines/Medical History/Medication/Allergies
List previous Travel Vaccines you have had?: Click or tap here to enter text.
Current illnesses OR Medical History of Note: Click or tap here to enter text.
Current medication: Click or tap here to enter text.
Allergies OR Anaphylaxis: Click or tap here to enter text.
YOUR TRAVEL DETAILS: Enter details of your trip- When, Where, and for how long are you going?
Date of departure: Click or tap to enter a date. Total duration of stay:Click or tap here to enter text.
Destination(s): Click or tap here to enter text.
Type of trip: Choose an item. Malarial area? ☐ Visiting an area at altitude >3000m? ☐
Travel Consult Fee payable in advance of your 1ST consultation is 30 Euro
Vaccinations Costs payable in advance
Illness	Vaccine Name	No. of doses	Cost per course	No. days between doses	When is a Booster Due
Diphtheria Tetanus Polio (Pertussis)	Revaxis or (Boostrix )	1	35 Euro	Single dose only	10yrs +
Hepatitis A	Avaxim	1	40 Euro	Single dose only	6-12 Months
Typhoid	Typhim	1	35 Euro	Single dose only	3 Years
Rabies	Verorab	3	105 Euro	7,21/28 days	If bitten
Hepatitis B	Engerix B	3	120 Euro	7,21days	12 months
Yellow Fever	Stamaril	1	40 Euro	Single dose only	Lifelong Protection
Meningococcal ACWY	Nimenrix	1	60 Euro	Single dose only	5 years
Measles Mumps Rubella	MMRVaxPro	1 or 2	Free	28 days	Lifelong Protection
Medication to prevent Malaria– Chosen based on your destination, side effects profile, and cost
Medication	DOXYCYCLINE*	MALARONE
Side Effects	Relatively common. Not usually serious Nausea /Vomiting/Diarrhoea/Dyspepsia/Thrush/Sunburn	Relatively rare. Not usually serious Nausea /Vomiting/Diarrhoea//Depression/Nightmares
Dosage	1 daily. Begin 2 days before enter area and continue daily until you stop 28 days after leaving area.	1 daily. Begin 2 days before enter area and continue daily until you stop 6 days after leaving area.

* A trial dose of Doxycycline is recommended 2-3 weeks pre-departure, to determine if tolerable and to ensure no significant side effects occur.

Note all anti-malarial medication is available to full Medical Card holders for Prescription Charge only Discuss cost with Pharmacist.

*COMPLETE THE GREEN SECTON ABOVE ANDP UPLOAD TO US VIA https://www.ucc.ie/en/studenthealth/yourhealthdata/accessing/