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  • 01254 369123
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Home > Travel Risk Assessment Form

Travel Risk Assessment Form

Patient Details
Travel Details
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Additional Trip Information
Purpose of Trip (tick all that apply)
Please provide details of your personal medical history
Please select all vaccines or malaria tablets you have had in the past

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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.

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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.


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Accrington Branch

387-391 Blackburn Road, Accrington, BB5 1RP

  • 01254 369123

Blackburn Branch

1A Pritchard Street, Blackburn, BB2 3PF

  • 01254 369123

Oswaldtwistle Branch

274 Union Road, Oswaldtwistle, BB5 3JB

  • 01254 369123
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