Travel Questionnaire

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.

1Personal details

2Dates of trip

3Itinerary and purpose of visit

4Please choose from the drop down lists how best to describe your trip

5Personal medical history

6Vaccination history

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

To be signed at appointment
To be dated at appointment

Privacy Protection

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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

27 Parkfield Road , Coleshill, Warwickshire, B46 3LD
Supplied by Marika Solutions Site powered by GP Fusion
Back to top