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Travel Questionnaire

Once you have completed the form below please contact the surgery to make your appointment.

Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.

1Personal Details

2Dates of Trip

3Itinerary and purpose of visit:

4Please check the boxes below to best describe your trip

5 Personal Medical History

(if not applicable please leave empty)

6Vaccination History


For discussion when risk assesment is performed within your appointment: I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questi

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Your Neighbourhood Professionals. Just a Click Away!
© Neighbourhood Direct Ltd 2018
Great James Street Health Centre, Great James Street, Derry, BT48 7DH
  • Telephone 028 7137 8500
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Your Neighbourhood Professionals. Just a Click Away!
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