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We use secure, NHS approved software to provide video consultations safely and effectively for our patients.

We use secure, NHS approved software to provide video consultations
safely and effectively for our patients.

Download Dr. iQ - our practice mobile app:
The fastest way to access our GP services

Download Dr. iQ -
our practice mobile app:

The fastest way to access our GP services.

New patients can register with our practice via Dr. iQ

Register with us

Conduct online consultations

Update your profile

View medical records

Order medications

Download Dr. iQ

Dr. iQ QR code

Dr. iQ mobile screen

Increase cases of measles

Measles can spread to other people easily.

Patients who have an appointment to come into the practice should not attend if they have:

a fever and a rash; with
cold symptoms;
or a cough;
or red, sore eyes (conjunctivitis)

Please contact the surgery and one of our clinicians will call you back.

For more information on measles, please visit the NHS website.

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Hickings Lane Medical Centre

Hickings Lane Medical Centre

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Hickings Lane Medical Centre

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Form Test

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Form Test

Travel Risk

Travel risk assessment form

Travel risk assessment form

Select your practice *

Full name *

Date of birth *

Sex at Birth *

Please select your sex as recorded at birth.

Gender *

Please select the gender that you most identify with.

Other (Please specify)

Email address *

Date of departure *

Return date *

Please give details of country to be visited, length of stay, and how remote you'll be from medical help *

Type of trip (Select all applicable) *

Business

Pleasure

Other

Other (Please specify)

Holiday type (Select all applicable) *

Package

Self organised

Backpacking

Camping

Cruise ship

Trekking

Accommodation (Select all applicable) *

Hotel

Relatives / family home

Other

Other (Please specify)

Travelling (Select all applicable) *

Alone

With family / friend

In a group

Staying in area which is... (Select all applicable) *

Urban

Rural

Altitude

Planned activities (Select all applicable) *

Safari

Adventure

Other

Other (Please specify)

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

Women only: Are you pregnant or planning pregnancy or breast feeding?

Yes

No

Don't know

Have you taken out travel insurance and if you have a medical condition, have you informed the insurance company about this? *

Yes

No

Don't know

Please write below any further information which may be relevant

Have you ever had any of the following vaccinations / malaria tablets? (Select all applicable)

Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other / Malaria tablets

Which year did you have the Tetanus vaccination?

Which year did you have the Polio vaccination?

Which year did you have the Hepatitis A vaccination?

Which year did you have the Hepatitis B vaccination?

Which year did you have the Meningitis vaccination?

Which year did you have the Yellow Fever vaccination?

Which year did you have the Influenza vaccination?

Which year did you have the Rabies vaccination?

Which year did you have the Jap B Enceph vaccination?

Which year did you have the Tick Bourne vaccination?

Which year did you have the Diphtheria vaccination?

Which year did you have the Typhoid vaccination?

If 'Other / Malaria tablets' please list here: *

Which year did you have the other vaccination / malaria tablets?

Patient Signature *

Text

Text

Text

Text

Text

Text

Text

Text

If you are human, leave this field blank.

Sicknote Fee

Sick Note (Fit Note) Request Form - Fee Required

Sick Note (Fit Note) Request Form - Fee Required

Select your practice *

Surgery Name

Surgery Name

Surgery Name

Surgery Name

Surgery Name

Surgery Name

First name *

Last name *

Date of birth *

Mobile number *

Email address *

Please tell us about your illness in as much detail as possible and how this is affecting your ability to work:

Please tell us the date you need the medical certificate to start from:

Start Date *

End Date *

Text

Text

Text

Text

Text

product name

If you are human, leave this field blank.

Sicknote No Fee

Sick Note (Fit Note) Request Form - No Fee Required

Select your practice *

First name *

Last name *

Date of birth *

Mobile number *

Email address *

Please tell us about your illness in as much detail as possible and how this is affecting your ability to work:

Please tell us the date you need the medical certificate to start from:

Start Date *

End Date *

Text

Text

Text

Text

Text

Text

Text

Text

If you are human, leave this field blank.

Covid

coronavirus-email

coronavirus-email

Email *

Text

If you are human, leave this field blank.

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Hickings Lane Medical Centre