Please complete the self-referral form below. If you require urgent or last minute advice please email us on: uclh.htdtravelclinic@nhs.net and we will attempt to expedite your appointment. If you do not hear from us within 5-7 working days, please call us on 020 3447 5968. 

If you are one of our corporate clients, please do not fill out the form; instead, email us directly.

If you are self-referring for post-tropical screening, please note this service is only suitable for people who have returned from their travels more than three months ago and don’t have any symptoms but are worried that they may be at risk.

Required appointment type Required
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3. Date of birth Required
5. Your address Required
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8. GP name and address
9a. Departure date Required
9b. Return date Required
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10. Medical and mental health history Required
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13. Do you need an interpreter for your appointment (including British Sign Language)? Required
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Please note we share information with other professionals responsible for your care including your GP.

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