Travel Risk Assessment

Please complete our online form

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Personal Details

Please note

This form needs to be completed at least four weeks before travel and will take up to two weeks to be actioned. If you are travelling at short notice, you will need to seek advice from a private travel clinic. Local pharmacies may offer travel advice and you may find advice online. We recommend Travel Health Pro.

We can only provide travel vaccinations that the NHS supply. We no longer have capacity to provide a private travel service.

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Gender: *

May be used to identify you

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

Personal Medical History

Including diabetes, heart or lung conditions

Have you ever had a serious reaction to a vaccine given to you before?:

Does having an injection make you feel faint?:

Do you or any close family members have epilepsy?:

Do you have any history or mental illness including depression or anxiety?:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?:

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?:

Vaccination History

Please select any previous vaccinations you have received, and the date, if known.

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.

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Travel Risk Assessment

Please complete our online form

Please note

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