Skip to main content
  • Language
    • Afrikaans
    • Albanian
    • Arabic
    • Armenian
    • Azerbaijani
    • Basque
    • Belarusian
    • Bengali
    • Bulgarian
    • Catalan
    • Chinese (Simplified)
    • Chinese (Traditional)
    • Croatian
    • Czech
    • Danish
    • Dutch
    • Esperanto
    • Estonian
    • Filipino
    • Finnish
    • French
    • Galician
    • Georgian
    • German
    • Greek
    • Gujarati
    • Haitian Creole
    • Hebrew
    • Hindi
    • Hungarian
    • Icelandic
    • Indonesian
    • Irish
    • Italian
    • Japanese
    • Kannada
    • Korean
    • Lao
    • Latin
    • Latvian
    • Lithuanian
    • Macedonian
    • Malay
    • Maltese
    • Norwegian
    • Persian
    • Polish
    • Portuguese
    • Romanian
    • Russian
    • Serbian
    • Slovak
    • Slovenian
    • Spanish
    • Swahili
    • Swedish
    • Tamil
    • Telugu
    • Thai
    • Turkish
    • Ukrainian
    • Urdu
    • Vietnamese
    • Welsh
    • Yiddish
  • Text Size
    • Increase Text Size
    • Decrease Text Size
    • Reset Text Size
Library House Surgery Providing NHS services
Providing NHS services
Search
Show Main Menu
  • Home
  • Appointments
  • Prescriptions
  • Services
    • AAA Screening
    • Ear Syringing
    • End of Life Care
    • Fit Notes & Sick Notes
    • Non-NHS Fees
    • Online Services
    • Overseas Treatment
    • Phlebotomy
    • 7 Day Blood Pressure Monitoring
    • Electronic Frailty Index (EFI)
    • Sharps Disposal
    • Test Results
    • Travel Advice & Vaccinations
    • Treatment Room Services
    • Weight Loss Injections
  • Surgery Information
    • Core Values And Mission Statement
    • Opening Times
    • Meet The Team
    • News
    • Join The Surgery
    • Out of Area Patients
    • Patient Feedback and Practice Performance
    • Patient Participation Group
    • Policies
    • Teaching Practice
  • Information & Advice
    • Carers
    • Care in the Pharmacy
    • Contraception
    • COVID-19 & Flu
    • Find your NHS number
    • Gamble Aware
    • Live Well
    • Medicines A to Z
    • Mental Health and Wellbeing
    • My Planned Care - Hospital Treatment
    • Pregnancy Information
    • Self Help Guides
    • Struggling with your hearing?
    • Useful Links
    • Useful Phone Numbers
  • Contact Us
  • Zero Tolerance
Home > Travel Risk Assessment Form

Travel Risk Assessment Form

Ideally to be completed by traveller prior to appointment.

Travel Risk Assessment Form
Please Supply Information About Your Trip In The Sections Below
Type of travel and purpose of trip - please tick ALL that apply
Please supply details of your personal medical history

Women Only

Please supply information on any vaccines or malaria tablets taken in the past

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 and is accessed over a secure connection by nominated staff. We have 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.


Local Services
Taxi

Site

  • Sitemap
  • Back To Top

About

  • Disclaimer
  • Website Privacy
  • Website Accessibility
  • Cookies
  • Content Attribution

Contact

Library House Surgery

Avondale Road, Chorley, Lancashire, PR7 2AD

  • 01257 441 771
© Neighbourhood Direct Ltd  2025
Website supplied by Oldroyd Publishing Group

Loading...

Local Services
Taxi