Medical Tourism Pre-Travel Screening
Personal Information
Full Name
Date of Birth
Passport Number
Nationality
Contact Number
Email Address
Travel Details
Destination Country
Expected Arrival Date
Planned Length of Stay (days)
Purpose of Visit / Medical Procedure
Medical History
Existing Medical Conditions
Current Medications
Known Allergies
Previous Surgeries
Vaccination & Screening
Vaccinations Received (e.g. COVID-19, Hepatitis)
Recent Medical Tests/Results
Emergency Contact
Name
Relationship
Contact Number