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Travel Form

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.

Personal details
Dates of trip
Itinerary and purpose of visit

Please select as appropriate to best describe your trip
Personal medical history
Vaccination history

(Please bring details of any vaccinations you have received or plan to receive from any other clinic or pharmacy.

If you are not registered with this Practice please supply a vaccination history from your usual GP surgery).

Have you ever had any of the following vaccinations/immunisations and if so when?

Please give details of any other vaccinations you have received
Please provide details

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 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.

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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Mind - England Your Neighbourhood Professionals. Just a Click Away! Home Chairs UK Ltd