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, we advise at least 6 weeks before you travel. If you are travelling within the next 6 weeks then please contact the Surgery directly.

Otherwise, please complete this form which will then be reviewed by a member of the team within 2 working days. You will then be put down for a telephone call from either Raj the practice pharmacist or from one of the practice nurses within the following 7 working days, who can advise whether you will or will not require vaccinations based on the information provided.

This will also determine what NHS vaccinations the Surgery can provide. If your require further vaccinations which are outside the NHS, the surgery will refer you to a specialist travel clinic who can provide comprehensive advice, travel plans and what private vaccinations may be required.  The most local private clinic is Manor Pharmacy on Wetmore Road, Burton-On-Trent.

Travel Risk Assessment

If you currently do not have a fixed address, please enter in the address field no fixed abode.
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Holiday type:
Type of trip:
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):