Travel Risk Assessment

If you are travelling abroad please make sure you submit this form at least 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.

Please note this is for Dolphin House Surgery patients ONLY. We are no longer a Private Travel Vaccination Clinic.

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).
Date of Birth
Women Only: Is there any possibility you may be pregnant?
UK Departure Date
Please enter a number from 0 to 99999.
Further Information
Purpose of your trip
Holiday type
Planned Activities
Are you fit for travel?
Do you have any allergies?
This field is for validation purposes and should be left unchanged.