Travel Risk Assessment

If you are travelling abroad please make sure you submit this form atleast 6 weeks before your departure date. If your departure date is sooner, we may not be able to complete the course of immunisations in time to guarantee full immunity and may therefore recommend another local private health clinic.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Dolphin House Surgery Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please write your name. 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.