Travel Risk Assessment Form

Ideally this form is to be completed 8 weeks before travel as some vaccines may need to be given as a course over a few weeks

Travel Risk Assessment Form
Please supply information about your trip in the sections below
Please supply details of your Personal Medical History

Women only

All patients

Please supply information on any vaccines or malaria tablets taken in the past

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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Lowther Pavilion Private physiotherapist in Lancaster