Portcullis Surgery

Portcullis Lane, Ludlow, SY8 1GT Send us an online question or request

Telephone: 01584 872 939

We are OPEN,

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

This form is needed in order to assess your needs for your trip. Please do NOT fill in this form if you are NOT registered with our practice.

  • 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
    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
    08:30am to 06:00pm
    6.30-9.30pm Bookable in advance appointments only.Call 111 for advice OOH
  • Tuesday
    08:30am to 06:00pm
    6.30-8pm Bookable in advance appointments only. Call 111 for advice OOH
  • Wednesday
    08:30am to 06:00pm
    6.30-9.30pm Bookable in advance appointments only.Call 111 for advice OOH
  • Thursday
    08:30am to 06:00pm
    6.30-8pm Bookable in advance appointments only.Call 111 for advice OOH
  • Friday
    08:30am to 06:00pm
    6.30-9.30pm One Friday a month Bookable in advance appointments only.Call 111 for advice OOH
  • Saturday
    CLOSED
    9-5pm One Saturday a month Bookable in advance appointments only.Call 111 for advice OOH
  • Sunday
    CLOSED
    Call 111 for advice OOH
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