Travel Risk Assesment 

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Personal Details

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Once we have received your form this will be passed to the practice nurse to review your form along with your medical records and decide which vaccines are required. Some vaccine require payment these will be expected to be paid for prior to your next nurse appointment as we have to order them into the surgery. A receipt will be given as proof of purchase

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Dates and Trip Details
Personal Medical History
Including diabetes, heart or lung conditions
Signed & Dated
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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.


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