Travel Risk Assessment

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.

Where possible please submit travel forms at least 8 weeks before date of travel, otherwise we can not guarantee there will be time for an assessment to be completed or an appointment available.

Please see our Private Fees for Travel Vaccinations (Updated 01-08-17).

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
Including diabetes, heart or lung conditions

Please state which year you had the vaccination(s):

For Official Use

Travel vaccines recommended for this trip

Disease protection

Yes/No

Patient declined vaccine

Vaccine name, dose & schedule for PSD

Hepatitis A

Hepatitis B

Typhoid

Cholera

Tetanus

Diphtheria

Polio

Meningitis ACWY

Yellow Fever

Rabies

Japanese B Encephalitis

Other

Authorisation for Patient Specific Direction (PSD) Use

(e.g. weight of child)