Practice Staff

Doctors

Dr David Bass (m)

BSc, MBBS 1984 London, FPCert

Dr Neil Leigh-Collyer (m)

BSc, MBBS, 1985 London, MRCGP, FPCert

Dr Sylvia Bond (f)

MB ChB 1986 Bristol, DRCOG, DCH, FRCGP, DFFP, MILT

Dr Ian Quigley (m)

MBBS 1989 London, FRCGP, DMCC, FAWM, FRGS

Dr Ashlesha Dhairyawan (f)

MBBS 1999 London, DRCOG, DFFP, MRCGP, DipPCRheum

Dr Salmaan Awan (m)

MBBS 2004 London, MRCGP

Dr Yasmin Heerah (f)

MBBS 2001 London, MRCGP

Dr Punit Agarwal (m)

MBBS 2005

Dr Naima Shamsudin (f)

MBBS MRCGP

Dr Naznin Younas (f)

MBBS 2010 University of London

Nursing Team

Sister Tracy Quigley (f)

RGN ANP PgDip

Nurse Lorraine O'Grady (f)

Nurse Debbie Davie (f)

Nurse Niana Brema (f)

Nurse Yvonne Little (f)

Admin Team

Mrs Allison Lipman

Practice Manager

Janet Soane

Reception Manager

Sheila Gould

Deputy Reception Manager

Update Your Details

Order Your Prescriptions

Online Appointment Booking

Patient Participation Group

Download Practice Leaflet

Friends & Family Test

Self Care A-Z

Travel Questionnaire

Personal Details
Name
First Last
Sex
- Female
- Male
Date of Birth
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone Number
Email
Trip Dates
Departure
Duration (Days)
Itinerary
Country Duration (Days) Availability of Medical Help
Trip Description - please tick appropriate boxes
Purpose of Trip
- Select All
- Business
- Pleasure
- Other
Type of Trip
- Select All
- Package
- Self-Organised
- Backpacking
- Camping
- Cruise Ship
- Trekking
Accommodation
- Select All
- Hotel
- Friends/Family
- Other
Travelling
- Select All
- Alone
- Friends/Family
- In a group
Location Type
- Select All
- Urban
- Rural
- Altitude
Activity Type
- Select All
- Safari
- Adventure
- Other
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)
- Select All
- 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?
- Select All
- Tetanus
- Diphtheria
- Hepatitis A
- Meningitis
- Influenza
- Jap B Enceph
- Malaria Tablets
- Polio
- Typhoid
- Hepatitis B
- Yellow Fever
- Rabies
- 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 Staff

Doctors

Nursing Team

Admin Team

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