Travel Risk Assessment Form - Cwmfelin Medical Centre

Please complete this form if you are planning to travel abroad and would like travel health advice from the practice.

The information you provide helps us assess your travel plans, destination risks, vaccination history and any health needs before your trip.

Complete this form as early as possible

Please submit your travel risk assessment form as early as possible before you travel.

Some travel vaccines need to be given several weeks before travel, and some courses require more than one dose.

If you are travelling soon, you may also need to contact a private travel clinic or pharmacy offering travel health services.

Before completing the form

Please check reliable travel health information for every country you are visiting, including stopovers if you will be leaving the airport.

check recommended vaccines and malaria advice for your destination
make sure your routine UK vaccinations are up to date
bring or provide details of any previous travel vaccinations you have had
include all destinations, dates of travel and the type of trip, for example holiday, work, volunteering, backpacking or visiting family

Useful travel health websites

These websites provide reliable information about travel vaccinations, malaria prevention, outbreaks and country-specific travel health advice.

NHS 111 Wales: travel vaccinations Public Health Wales: travel vaccinations TravelHealthPro: country information Welsh Government: travel vaccinations

Please note

Some travel vaccinations are available on the NHS, but others are only available privately. The practice will advise you if a fee applies.

Completing this form does not guarantee that all recommended vaccines or medicines can be provided by the practice.

About you

Full Name

Address

Date Of Birth

For example, 15 3 1984

Day

Month

Year

Phone Number

Email Address

Further Information

List Destinations - Country or Resort (Include any stopovers on the journey)

Date of Travel

For example, 15 3 1984

Day

Month

Year

Length of Stay

TYPE OF ACCOMMODATION (e.g. hotel, self catering, camping, backpacking, etc )

Are you pregnant or might you be before you travel?

Sea

Níl

Please list any known allergies

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Sea

Níl