St. Mary's Surgery

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Travel Risk Assessment

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All questions marked with a * are mandatory

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.
We also may need to order the vaccinations that you require.

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Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Dates and Trip Details

Holiday Type: *

Accommodation: *

Travelling: *

Staying in area which is: *

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Signed & Dated

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This form collects personal and medical information about you and 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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