Performer Medical Travel Disclosure Form

Performer Information

Full Name Date of Birth Contact Number Email Address

Travel Details

Travel Destination (City, Country) Travel Dates Purpose of Travel

Medical Procedures Disclosure

Medical Procedure(s) to be Performed Medical Facility/Clinic Attending Physician

Additional Medical Information

Relevant Medical Conditions Current Medications Known Allergies

Emergency Contact

Name Relationship Contact Number

Disclosure & Certification

I hereby declare that the above information is accurate and complete to the best of my knowledge. Signature Date