Portcullis Surgery

Portcullis Surgery

Portcullis Lane, Ludlow, SY8 1GT

Current time is 21:51 - Sorry, we're closed

NHS

Telephone: 01584 872 939

Fax: 01584 879 031

portcullis.surgery@nhs.net

Portcullis Travel Risk Assessment Form

Please complete this form in the spaces below online and submit it via our website in order to book your appointment with the nurse prior to your travel appointment.

Alternatively you can print of the sheet below, fill it in and hand it in at reception

Travel Risk Assessment Form

You will need to book a 20minute appt with the nurse for the travel clinic.

Travel Risk Assessment Form

To register with our practice, ALL YOU NEED TO DO IS FILL IN THE FORM BELOW AND SUBMIT IT. Or you can print the forms and hand them in to reception or send them by post
  • Please add all relevant tel nos
  • Please include information about your ethnicity (optional)
    Please tick all the boxes that apply to your trip
    Please tick all those that apply to you
  • Please describe what happened
  • If you are not on any medication write none.
    Have you ever had any of the following vaccines? Please tick all relevant boxes. Please write down the approximate date you last had this vaccine.
  • Please describe how you got the clot and if it was related to travel
  • Passport or Driver's licence please. Ideally upload a photo straight away with this application or send it to us by email to portcullis.dutymanager@nhs.net. If you don't have either of these IDs, please fill in the form and call us. If you are registering a child a copy of their birth certificate or a parents ID may be acceptable.
    For close family members (parents, siblings, grandparents, children) Please tick all those that apply to your family
  • This field is for validation purposes and should be left unchanged.

Opening Times

  • Monday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Tuesday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Wednesday
    08:30 until 20:00
    6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Thursday
    08:30 until 18:30
    Call 111 for advice OOH
  • Friday
    08:30 until 20:30
    Open 1-2 Fridays a month. 6-8pm Pre-booked appointments only.Call 111 for advice OOH
  • Saturday
    08:30 until 12:30
    Open 1-2 Sat per month Pre-booked appointments only. Call 111 for advice OOH
  • Sunday
    CLOSED
    Call 111 for advice OOH