Travel Risk Assessment

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Personal Details

If you require any vaccinations relating to foreign travel you need to fully complete, sign and return this Travel Questionnaire Form at least 6 weeks before your date of travel.

When this has been received by the practice we will make a 20 minute appointment for the nurse to review the form, review your medical history and to establish the travel recommendations.   

Only when this has been completed will the nurse be able to see the provide you with an appointment.  At this appointment the nurse will discuss recommended travel vaccinations/immunisations and travel health advice, administer vaccinations/immunisations and book a follow up appointment if required

It is important to make this initial appointment as early as possible - at least 6 weeks before you travel - as a second appointment may be required with the practice nurse.

We are able to provide and administer those vaccines which are available under the NHS.  Patients will be advised to contact a private travel clinic to have these administered.

Please double check you've entered the correct email address
May be used to identify you
Dates and Trip Details
Personal Medical History
Including diabetes, heart or lung conditions
Signed & Dated
Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
Previous Page  
Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.