Travel Risk Assessment

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 in plenty of time before your journey and that you book an appointment 8-10 weeks in advance.

Travel Risk Assessment form

Travel Risk Assessment form

Please use this date format: DD/MM/YYYY.
Gender *
Registered GP Practice *
Please use this date format: DD/MM/YYYY.

Please tick as appopriate below to best describe your trip

Type of trip
Holiday type
Type of Area
Planned activities
Have you ever had any of the following vaccinations / malaria tablets?
Please write your name. I confirm I am fit and well. I have no reason to think that I might be pregnant. I give my consent to the vaccines being given.
Please use this date format: DD/MM/YYYY.

Certain vaccinations/courses will incur a charge, payment must be made prior to administration.
N.B. If malaria tablets are required there is a separate private prescription charge.

For Official Use only


Disease protection Yes No Discuss Disease Protection Yes No Discuss
Hepatitis A Yellow Fever* £60.00
Typhoid Meningitis ACWY* £70.00
Tetanus Rabies* (course) £180.00
Diphtheria Hepatitis B* (course) £120.00
Polio Japanese Enceph* (course) £170.00
Tickborne Enceph* (course) £180.00 Other
Consultation only regarding Malaria
Malaria tablets or discussion required
Nurse Appointment time
Please make your appointment at least _________ weeks prior to travel in travel clinic.