Thank you for applying for Lakenham Surgery Travel Service.
In order for us to provide a safe and appropriate service it is essential that the Travel Form is completed, a minimum of 8 weeks before the departure date, preferably 12 weeks.
If there is less than 8 weeks to departure it will be at the discretion of the practice as to whether the necessary assessment and appointments can be accommodated in the time remaining.
Fill the form out below, or download the form here and bring it in completed to the surgery.
Itinerary and purpose of visit
Please select as appropriate to best describe your trip
Personal medical history
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 known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.