Please ensure this form is completed atleast 3 working days prior to your travel vaccine appointment
Information entered into practice survey forms is used only for the purposes of processing your Survey information and is
stored and accessed securely by designated Practice staff.
Issues raised in comments may be discussed between relevant members of the Practice.
The information is used for quality monitoring purposes, in line with the expectations of the patients submitting
Any personal information transmitted via Practice Survey forms may be anonymised by the Practice when this
is required to ensure compliance with General Data Protection Regulation.
This information is not shared with any external third party organisations.
This information is kept for as long as the site is active or it is deleted by a site administrator.
I consent to my information being used for the purposes described above and wish to submit this online form to
The Upstairs Surgery
Ashton Gardens, Chadwell Heath, Romford, Essex, RM6 6RT.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.