Travel Questionnaire

This form must be completed before attending a travel appointment. The form will be sent to the practice electronically. You do not need to print off the form.

1Personal details

2Dates of trip

3Itinerary and purpose of visit

4Please choose from the drop down lists how best to describe your trip

5Personal medical history

6Vaccination history

For discussion when risk assessment is performed within your appointment:

I have no reason to think that I may be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questio

To be signed at appointment
To be dated at appointment

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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27 Parkfield Road , Coleshill, Warwickshire, B46 3LD
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