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Home
Appointments
Who Do I See?
How to book an Appointment
Routine Appointments
Same Day and Urgent Appointments
Appointments Information
Cancel or Change an Appointment
NHS 111 online – Get Help for your Symptoms
Hospital Appointments Information
Home Visits
Out of Hours – When we are closed
Prescriptions
About Us
Meet the Team
Clinical Team
Doctors
Nursing & Pharmacist Team
Pharmacists
Management & Administration
Recruitment
Job Applicant Privacy Notice
Patient Feedback
Complaints
Leave a Review
Feedback
Friends and Family Test
Patient Participation Group
Advocacy Service
Patient Survey
Practice Policies
London Care Record
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding Children
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Choose if data from your health records is shared for research and planning
Summary Care Record
The National Care Record Service (NCRS)
Organ Donation
Sharing your Information with Others
How we use your Data
Confidentiality
Privacy Policy
Online Access
Register for Online Services Form
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website Policies
Accessibility
Online Forms
Childhood Immunisation Appointment request form
Request Fit Note
Medical Information Request Form
Register as a Carer Form
Summary Care Record Opt-out Form
Travel Risk Assessment Form
PPG Registration Form
COVID Vaccine Enquiry Form
Medication Request Form
Feedback
Patient Participation Group Survey
Smear ( Cervical Screening) Appointment request
BP Readings Form – POD
Flu Appointment request
Staff Self Certification form
Copyright
Cookie Policy
Disclaimer
Documentation
Child Immunisation information
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Care Quality Commission
Register with Us
Sick Notes
Clinics and Services
Vaccinations
Travel Vaccinations
Children Routine Vaccinations
Hepatitis B Immunisation
Shingles Vaccination
Pneumococcal Vaccine
Whooping cough vaccination
RSV Vaccination
Travel Vaccinations
Request for Letters & Reports
Appointments Attendance Confirmation to School
Change of Contact Details Form
Smear Test (Cervical Screening)
Test Results
Pregnancy
Post Natal Checks
Child Health Checks
Find your Local Services
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
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Health Review Forms
Alcohol Consumption Review Form
BP – Blood Pressure readings form
Smoking Review Form
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Female Contraception
Weight Management Programme
Home Blood Pressure Monitoring
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Travel Risk Assessment Form
Travel Risk Assessment Form
Travel Risk Assessment
First Name
*
Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Gender
*
Male
Female
Date of Departure
*
Please use format day/month/year e.g. 12/05/2019
Date of Return
*
Please use format day/month/year e.g. 12/05/2019
Please give details of country to be visited, length of stay, and how remote you’ll be from medical help
*
Accommodation
*
Hotel
Relatives / family home
Other
Holiday Type – PLEASE TICK ALL PROPRIATE
Resort
Camping
Rural Area
City Area
Safari
Adventure
Backpacking
Cruise
Travelling
*
Alone
With family / friend
In a group
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
*
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
*
Have you ever had a serious reaction to a vaccine given to you before?
*
Yes
No
Don’t Know
Does having an injection make you feel faint?
*
Yes
No
Don’t Know
Do you or any close family members have epilepsy?
*
Yes
No
Don’t Know
Do you have any history or mental illness including depression or anxiety?
*
Yes
No
Don’t Know
If yes please specify:
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
*
Yes
No
Don’t Know
If yes please specify:
Are you pregnant or planning a pregnancy or breast feeding?
Yes
No
Don’t Know
Not Applicable
If yes please specify:
Do you, your partner or any of your parents come from a community or area where Female Genital Mutilation (FGM) or circumcision is practiced?
Yes
No
Don’t Know
Not Applicable
Have you taken out travel insurance?
*
Yes
No
Don’t Know
Please type below any further information which may be relevant:
Have you ever had any of the following vaccinations / malaria tablets?
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Malaria tablets
Other
Other
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
If you are human, leave this field blank.
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Appointments
Who Do I See?
How to book an Appointment
Routine Appointments
Same Day and Urgent Appointments
Appointments Information
Cancel or Change an Appointment
NHS 111 online – Get Help for your Symptoms
Hospital Appointments Information
Home Visits
Out of Hours – When we are closed
Prescriptions
About Us
Meet the Team
Clinical Team
Doctors
Nursing & Pharmacist Team
Pharmacists
Management & Administration
Recruitment
Job Applicant Privacy Notice
Patient Feedback
Complaints
Leave a Review
Feedback
Friends and Family Test
Patient Participation Group
Advocacy Service
Patient Survey
Practice Policies
London Care Record
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding Children
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Choose if data from your health records is shared for research and planning
Summary Care Record
The National Care Record Service (NCRS)
Organ Donation
Sharing your Information with Others
How we use your Data
Confidentiality
Privacy Policy
Online Access
Register for Online Services Form
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website Policies
Accessibility
Online Forms
Childhood Immunisation Appointment request form
Request Fit Note
Medical Information Request Form
Register as a Carer Form
Summary Care Record Opt-out Form
Travel Risk Assessment Form
PPG Registration Form
COVID Vaccine Enquiry Form
Medication Request Form
Feedback
Patient Participation Group Survey
Smear ( Cervical Screening) Appointment request
BP Readings Form – POD
Flu Appointment request
Staff Self Certification form
Copyright
Cookie Policy
Disclaimer
Documentation
Child Immunisation information
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Care Quality Commission
Register with Us
Sick Notes
Clinics and Services
Vaccinations
Travel Vaccinations
Children Routine Vaccinations
Hepatitis B Immunisation
Shingles Vaccination
Pneumococcal Vaccine
Whooping cough vaccination
RSV Vaccination
Travel Vaccinations
Request for Letters & Reports
Appointments Attendance Confirmation to School
Change of Contact Details Form
Smear Test (Cervical Screening)
Test Results
Pregnancy
Post Natal Checks
Child Health Checks
Find your Local Services
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Carers
Health Review Forms
Alcohol Consumption Review Form
BP – Blood Pressure readings form
Smoking Review Form
Texting Service
Radiology Requests
Self Referrals
Physio
Help & Support Services
Stop Smoking Services
Female Contraception
Weight Management Programme
Home Blood Pressure Monitoring
Help & Support Services
Live Well Greenwich
Online Services