Western Road Medical Centre

99 Western Road, Romford, Essex, RM1 3LS

It's Sunday 3:52 AM — Sorry, we're closed

Telephone: 01708 775300

Fax: 01708 737936

Practice Boundary

Please call the surgery on 01708 775300 to check whether you are within the practice’s boundary. Thank you.

Our Practice Boundary runs from the A12 Eastern Avenue and includes Ardleigh Green Road, Butts Green Road, Billet Lane, Hornchurch Road, Rom Valley Way, Waterloo Road, St Edwards Way and North Street.

** If you are unclear and need to clarify our Boundary Areas please telephone the surgery on 01708 775300 and speak to one of our receptionists who will be happy to assist.

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Travel Questionnaire

Personal Details
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Date of Birth
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
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Departure
Duration (Days)
Itinerary
Country Duration (Days) Availability of Medical Help
Trip Description - please tick appropriate boxes
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Personal Medical History
List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)
List all allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
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- Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?
- Does having an injection cause you to feel faint?
- Do you or any close family members have epilepsy?
- Do you have any history of mental illness including depression or anxiety?
- Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
- Have you taken out travel insurance?
- If you have a medical condition, have you told your insurance company about it?
- Are you pregnant, planning pregnancy or breast feeding?
Write below any further information that might be relevant
Vaccination History
Have you ever had any of the following vaccinations / tablets and if so, when?
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- Tetanus
- Diphtheria
- Hepatitis A
- Meningitis
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- Jap B Enceph
- Malaria Tablets
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- Yellow Fever
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- Tick Borne
- Other
If other please state

Opening Times

Monday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Tuesday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Wednesday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Thursday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Friday
Open (Basic queries only): 08.00am l Clinics start: 9:00 l Close: 6.30pm
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Country	Duration (Days)	Availability of Medical Help

Western Road Medical Centre

Practice Boundary

Update Your Details

Patient Participation Group

Friends & Family Test

Travel Questionnaire

Personal Details

Trip Dates

Itinerary

Trip Description - please tick appropriate boxes

Personal Medical History

Vaccination History

Opening Times

Useful Links