Travel Risk Assessment Please complete the form below to get more information about what travel immunisations you require. Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 weeks).Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date of Birth Day Month Year Contact NumberAddress Street Address Address Line 2 City Postcode Email Enter Email Confirm Email Women Only: Is there any possibility you may be pregnant? Yes Optional No Optional Destination(s)UK Departure Date Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.Country being visited (specify areas if long haul)Length of stay (include stopover destinations)Are you visiting more that one country? Yes No Please specifyCountry being visited (specify areas if long haul) and Length of StayFurther InformationPurpose of your tripBusinessPleasureOtherHoliday typePackageSelf organisedBackpackingCampingTrekkingCruise ShipOtherAccommodationAloneWith friends &/or FamilyGroupOtherSettingUrbanRuralAltitudeOtherPlanned ActivitiesSafariAdventureOtherAre you fit for travel? Yes No Do you have any allergies? Yes No Please state allergiesDo you have any other information you would like to disclose? Yes No Please specify
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