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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

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. 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!
Great James Street Health Centre, Great James Street, Derry, BT48 7DH
  • Telephone 028 7137 8500
Website supplied by Oldroyd Publishing Group
Your Neighbourhood Professionals. Just a Click Away!
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