Travel Medical Disclosure Form
Personal Information
Full Name
Date of Birth
Contact Number
Email Address
Emergency Contact
Contact Name
Relationship
Phone Number
Medical Information
Existing Medical Conditions
Allergies (including medications, food, etc.)
Current Medications
Primary Physician Name
Primary Physician Contact
Insurance Information
Insurance Provider
Policy Number
Other Notes
Additional Information or Special Needs
I attest that the above information is correct to the best of my knowledge.
I give consent for emergency medical treatment if needed during travel.