Travel Risk Assessment

For all risk assessments you must be an active, registered patient with Chapel Row Surgery.

With effect from 1st March 2022 there will be a £20 surcharge fee for any risk assessments submitted less than 4 weeks prior to departure.

This will be added to your invoice should you require any vaccinations.

We will aim to respond to you as quickly as we are able, please check your junk mail for replies. Once we have completed the assessments, we will advise you of any appointments that need to be made, please call Reception on 0118 971 3252 to book.

Travel Risk Assessment

Travel Risk Assessment

Section

Date of Departure

Please use this format: DD/MM/YYYY

Are you flying direct to your destination?

Yes

No

Please list all the countries (including exact location/region) you are visiting, including total length of each stay.

Please state any stopovers for more than 12 hours

Total length of trip

Type and purpose of trip

Please specify what kind of activities you will be undertaking e.g. water sports or animal encounters:

What kind of accommodation will you be staying in?

Do you plan to travel abroad again in the future?

Yes

No

Have you taken out insurance for this trip?

Yes

No

Are you fit and well?

Yes

No

Are you pregnant or planning to conceive?

Yes

No

Are you allergic to anything?

Yes

No

Please list your known allergies

Have you had a reaction to a vaccine before?

Yes

No

Are you immunocompromised?

Yes

No

Do you have a spleen?

Yes

No

Are you undergoing any treatment for cancer or waiting for surgery?

Yes

No

Please give details of any further details about your health we should be aware of:

*

I confirm that the information provided is accurate to the best of my knowledge.

If you are human, leave this field blank.