Travel Risk Assessment

Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)
Personal Details

If you are planning to travel abroad, we kindly request that you contact us at least 6 weeks before your departure date. This will allow us to arrange any necessary vaccinations that may be required for your destination. To ensure that our travel nurses are able to assess your specific travel needs, it is important that they have access to the assessment form before your appointment.

Please double check you've entered the correct email address
May be used to identify you
Dates and Trip Details
Personal Medical History
Including diabetes, heart or lung conditions
Signed & Dated
Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.