This website has been provided to Lyme Bay Medical and Dental Practices - Deleted 3-5-2017 for evaluation purposes, and should not be used by Patients. ×

Travel Risk Assessment Form

Please complete this form prior to your appointment. Alternatively, you can download a printable version of the form by following this link.

1Personal Details

2Dates of Trip

3Itinerary / Purpose of Visit - Country #1

4Itinerary / Purpose of Visit - Country #2

5Itinerary / Purpose of Visit - Country #3

6Additional Destination Countries

7Nature of Trip

8Personal Medical History

9Vaccination History

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.

© Lyme Bay Medical and Dental Practices - Deleted 3-5-2017 2019
Kent House Health Centre, Silver Street, Lyme Regis, Dorset, DT73HT
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