Medical Travel Authorization Form
Patient Information
Full Name
Date of Birth
Passport/ID Number
Contact Number
Email Address
Address
Travel Details
Destination Country
Purpose of Travel
Departure Date
Return Date
Medical Information
Medical Condition
Treating Physician
Hospital/Clinic Name
Address of Medical Facility
Accompanying Person(s) Details
Name(s)
Relation to Patient
Authorization
Authorized By (Name)
Date
Signature