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Home > Services > Travel Clinic > Travel Risk Assessment
Before booking a Travel Clinic, we kindly ask that you input and submit your details using the following Travel Risk Assessment form:
Date of Birth
Country of Origin
Date of Departure
Length of Trip
Name of Country(s)
Length of Stay
City / Rural
CityRuralCity & Rural
Do you have Travel Insurance?
Do you plan to travel again?
Are you taking any medication (prescribed or over the counter)?
Do you have any allergies (including food, latex or medication)?
Do you tend to faint with injections?
Have you had any surgical operations in the past, including your spleen or thymus gland removed?
Have you recently had chemotherapy, radio therapy or an organ transplant?
Women Only: Are you currently pregnant or breast feeding?
Women Only: Are you planning a pregnancy in the next 3 months whilst away?
Tetanus / Polio / Diphtheria
Tick Borne Encephalitis
Please Note: A member of the Support Team will contact you within 2 working days following receipt of your assessment.