Travel Risk Assessment

If you are travelling abroad please make sure you submit this form atleast 6 weeks before your departure date. If your departure date is sooner, we may not be able to complete the course of immunisations in time to guarantee full immunity and may therefore recommend another local private health clinic.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

If you’re planning on travelling in less than 6 weeks time we advise that you contact a private travel service, for their advice and have their injections if advised at a cost.

Local travel centres:

See our Travel price list.

Castlegate Surgery Travel Risk Assessment

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Previous vaccines, please tick and give approximate dates

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY

Which Countries do you intend to visit? (please list all including stopovers):

Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

Travel Vaccine Record (Nurses use only)

Section 1

This details what you are already covered against as recorded in your NHS notes. We do not have any record of immunisations you may have had at school, work or privately.

Section 2

(If malaria advice alone is all that is required then only one member of the family need make an appointment)

I recommend the above named person to have the vaccines / anti-malaria tablets indicated and / or to contact a dedicated travel clinic / service for specialist advice / vaccines.