Travel Risk Assessment Form

Before you complete this form it is important that you read the following information, failure to comply with guidelines may result in the Practice being unable to provide you with this service.

The form must be completed at least 4 weeks before your date of first travel to ensure that there is enough time to have all your vaccinations.

  1. All sections of the form must be completed in full.
  2. Once you have completed and submitted this form, please contact the surgery after 5 working days to confirm vaccinations recommended.
  3. One form must be completed by each traveller prior to your appointment.


A private prescription may ne needed for some Malaria tablets, and there will also be a charge for this by the Chemist for the medication. Some vaccinations will be charged for: Hepatitis B, Meningitis ACWY, Rabies and Cholera as they are not covered by the NHS. The following injections are available free of charge:

  1. Hepatitis A
  2. Typhoid
  3. Combined Polio/Diphtheria/Tetanus

Travel Itinerary

Previous Vaccination History

Hepatitis A 1st or Bst
Hepatitis B 1st, 2nd, 3rd, 4th
Yellow Fever