Travel Risk Assessment Form

Please complete this form prior to your travel clinic appointment.

Destinations

Number of Adults

Number of Children

Departure Date

Length of Stay (Days)

Activities Planned

Medical Conditions

Current Medications

Previous Travel Vaccinations

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

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