Travel Risk Assessment Form

Please complete this form prior to your travel clinic appointment.

Phone Number

Destinations

Departure Date

Length of Stay (Days)

Activities Planned

Total Number of Travellers (Adults & Children)

I consent to the clinic checking my GP Summary Care Record to confirm my vaccination history.

lockwoodpharmacy

We work hard to provide you with a high quality service at all times.

227-231 Lockwood Road
Huddersfield
HD1 3TG

Lockwood Pharmacy

Top