Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Chapel Row Surgery Professional services from a team who care

Travel risk assessment

Travel Risk Assessment

Section

Date of Departure

Please use this format: DD/MM/YYYY

Are you flying direct to your destination?

Yes

Please list all the countries (including exact location/region) you are visiting, including total length of each stay.

Please state any stopovers for more than 12 hours

Total length of trip

Type and purpose of trip

Please specify what kind of activities you will be undertaking e.g. water sports or animal encounters:

What kind of accommodation will you be staying in?

Do you plan to travel abroad again in the future?

Yes

Have you taken out insurance for this trip?

Yes

Are you fit and well?

Yes

Are you pregnant or planning to conceive?

Yes

Are you allergic to anything?

Yes

Please list your known allergies

Have you had a reaction to a vaccine before?

Yes

Are you immunocompromised?

Yes

Do you have a spleen?

Yes

Are you undergoing any treatment for cancer or waiting for surgery?

Yes

Please give details of any further details about your health we should be aware of:

I confirm that the information provided is accurate to the best of my knowledge.

If you are human, leave this field blank.

The Avenue
Bucklebury
Berkshire
RG7 6NS

Get directions

0118 971 3252

Feedback and complaints

Wellbeing

Accessibility statement

Website policies