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Peartree Surgery: 01708 852 318
West Horndon Surgery: 01277 811 770
Out of hours: 111
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Peartree Surgery & West Horndon Surgery
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Keep us up to Date
Change of Contact Details Form
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Health Review Forms
Alcohol Consumption Review Form
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Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Help & Support
News
Menu
Home
About Us
Contact
Contact Telephone Numbers
Location
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Have your Say
Healthwatch Thurrock
Compliments and Suggestions
Friends and Family Test
Complaints
Patient Opinion
Patient Participation Group
Making the most of your Practice
Opening Hours
What to do when we are closed
Our Team
Doctors
Partners
Nurse
Practice Team
Our Allied Health Professionals
Practice Policies
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding Children and Adults
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
The National Care Record Service (NCRS)
Data Sharing Preferences
Multi-Disciplinary Teams
Choose if data from your health records is shared for research and planning
Organ Donation
Sharing your Information with Others
Summary Care Record
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website Policies
Accessibility
Copyright
Cookie Policy (UK)
Disclaimer
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Appointments, Tests & Referrals
Appointments
NHS 111 online – Get help for your Symptoms
Book an Appointment
Cancel an Appointment
Evening and Weekend appointments
Help with your GP Appointment
Hospital Appointments – Book, Cancel or Change
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access Your Test Results
Other Common Tests
Urine Tests
X-Rays & Scans
What is a Blood Test?
Who Do I See?
Clinics & Services
Clinics
Antenatal Care
Child Health Checks
Clinics we provide
Long Term Conditions
NHS Health Check aged 40 – 74
Travel Clinic & Holiday Vaccinations
Avoidance Admission/Designated GP
Online Services
Register for Online Services
NHS App
Practice Services
Advocacy Service
Dementia Services
Cervical Screening
Diabetes Services
Hepatitis B Immunisation
Register with us as a New Patient
Further Help about how to Register with a GP
Registration Policy
Temporary Services
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
NHS screening
Non NHS Services – Chargeable
Order a Repeat Prescription
Antibiotic Use
Wasted Medications
Electronic Prescriptions
Patient Transport Service
Sick/Fit Note
Texting Service
Vaccinations
Primary Care Network Extended Access Services
Your Record
Keep us up to Date
Change of Contact Details Form
Communication Consent Form
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Upload photos or documents
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
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Travel Risk Assessment Form
Travel Risk Assessment Form
Travel Risk Assessment
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Gender
*
Male
Female
Date of Departure
*
Please use format day/month/year e.g. 12/05/2019
Date of Return
*
Please use format day/month/year e.g. 12/05/2019
Please give details of country to be visited, length of stay, and how remote you’ll be from medical help
*
Type of trip
*
Business
Pleasure
Other
Holiday type
*
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
Accommodation
*
Hotel
Relatives / family home
Other
Travelling
*
Alone
With family / friend
In a group
Staying in area which is
*
Urban
Rural
Altitude
Planned activities
*
Safari
Adventure
Other
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
*
List any current or repeat medications
*
Do you have any allergies for example to eggs, antibiotics, nuts?
*
Have you ever had a serious reaction to a vaccine given to you before?
*
Yes
No
Don’t Know
Does having an injection make you feel faint?
*
Yes
No
Don’t Know
Do you or any close family members have epilepsy?
*
Yes
No
Don’t Know
Do you have any history or mental illness including depression or anxiety?
*
Yes
No
Don’t Know
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
*
Yes
No
Don’t Know
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
*
Yes
No
Don’t Know
Please type below any further information which may be relevant:
Have you ever had any of the following vaccinations / malaria tablets?
*
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other / Malaria tablets
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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