Travel Risk Assessment

TRAVEL RISK ASSESSMENT FORM

To be completed by traveller prior to appointment – PLEASE SUBMIT FORM AT LEAST 6 WEEKS BEFORE TRAVEL

PLEASE SUPPLY INFORMATION ABOUT YOUR TRIP IN THE SECTIONS BELOW

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.