Travel Questionnaire

 

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Personal Details

Only complete this form once you have booked your initial telephone consultation with the nurse and have been directed to do so.  If you have not booked a telephone consultation, please call the surgery on 02082917007 to arrange.

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Please note you need to enter your Date of Birth in the format: DD/MM/YYYY
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
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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