Travel risk
assessment

Our practice nurse holds a travel vaccination clinic for our patients. It is essential that you plan ahead at least six weeks prior to travel to ensure that you have the vaccinations you need for your journey.

Please complete the form below regarding your place of travel at least one week before your first appointment is needed.

1. About you

2. About your Trip

3. Signed

1. About you

Which Practice are you visiting?

Practice Entries Email

First Name

Last Name

Date of birth

Email Address

3. Signed

For discussion when risk assessment is performed within your appointment:

I have no reason to think that I might be pregnant.
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.

Any more relevant information?

Your Name

Date