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  • 01202 411700
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The Panton Practice Providing NHS services
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Home > Patient Travel Questionnaire

Patient Travel Questionnaire

Please complete this form at least 8 Weeks prior to travel.

Where possible make an appointment at least 6 weeks before you travel.

A form should be completed for each person who will be travelling.

Patient Details
Country 1
Country 2
Country 3
Country 4
Travel Information (please tick all that apply)
Purpose of Travel
Method of Travel
Accommodation
Activities
Medical History

Women only

We recommend travelhealthpro.org.uk
Information on any vaccines or malaria tablets taken in the past (please add date if given)
Allergies
Medications

Please amend this as necessary (include prescribed, purchased or contraceptive pill)


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.


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Gervis Road Surgery

14 Gervis Road , Bournemouth , BH1 3EG

  • 01202 411700

St Leonard's Road Surgery

20 St Leonard's Road, Charminster, Bournemouth , BH8 8QN

  • 01202 411700
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Local Services
Aesthetic
Clinic
Funeral
Plans
Home
Care
Jobs
Residential/
Nursing Care
Taxi
Residential/
Nursing Care Jobs
Wills
& LPA
Day
Nursery
Domiciliary
Care Agency