Travel Risk Assessment

Please see the Travel Vaccination Advice page for further details regarding travel vaccinations.

Please note Clifton Road Surgery can only provide you with the free NHS vaccines for your travel (if needed). If other vaccines are needed you will have to either visit a private travel vaccination clinic or check which pharmacies are offering travel healthcare services.

To book for the free NHS vaccines you will need to complete this form fully.

It is essential that one form is filled out per patient travelling, and not to have one form for multiple people. Once completed, we will review this and contact you to arrange a mutually convenient time for you to come and have the necessary vaccinations.

Please note this process can take up to 2 weeks. We do recommend that you submit your form at least 6-8 weeks before your date of travel. This allows the nurse to look through your immunisation history, and to order in any vaccines that may be needed.

Travel Risk Assessment

Travel Risk Assessment

Sex:
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
Accommodation:
Travelling:
Staying in area which is:
Planned activities:
Including diabetes, heart or lung conditions
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Have you ever had any of the following vaccinations / malaria tablets?

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

*