Travel Clinic

Travel Risk Assessment Form

About You

Please include all your given names.
Please use this date format: DD/MM/YYYY.
Please include postcode.

About Your Trip

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Medical History

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.
Please use this date format: DD/MM/YYYY.

Please note that the details you give will be used to update your medical records.