Travel Risk Assessment

Please note that we are not always able to provide appointments for holiday/travel vaccinations at short notice. Therefore, as most vaccinations need to be completed at least six weeks before departure, if you are intending to travel in less than six weeks and we are unable to complete the course of vaccinations in time to guarantee full immunity we may advise you to make arrangements to have your vaccinations at a private travel clinic.

The nearest travel clinic is located at Dolphin House Surgery in Ware, telephone number 07873 876648.

You can also download and print the Travel Risk Assessment form.

Travel Risk Assessment - Hanscombe
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Sex: *

Trip Details

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Type of trip:
Holiday type:
Staying in an area which is:
Planned activities:

Personal Medical History

Have you ever had a serious reaction to a vaccine?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have any history or mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Have you taken out travel insurance and informed the company of any medical condition you may have?
Have you ever had a Hepatitis A infection?

Vaccination History

Have you ever had any of the following vaccinations / malaria tablets?
Please bring a copy of your original certificate to 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.