Travel Risk Assessment

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As you are travelling in less than 8 weeks, you are advised to attend a Travel Clinic.

Please access National Travel Health Network and Centre (NaTHNaC) for travel health information.

Please proceed to the next page to complete the form.

Personal Details
Please double check you've entered the correct email address
May be used to identify you
Dates and Trip Details
Personal Medical History
Including diabetes, heart or lung conditions
Women Only
Signed & Dated
Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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