This form must be completed before attending a travel appointment. The form will be sent to the practice electronically. You do not need to print off the form.
For discussion when risk assessment is performed within your appointment:
I have no reason to think that I may be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questio
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Hazelwood Group Practice
27 Parkfield Road , Coleshill, Warwickshire, B46 3LD.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.