Business Traveler Medical Information Declaration Form
Personal Information
Full Name
Date of Birth
Passport Number
Country of Residence
Travel Information
Destination Country
Travel Dates
Purpose of Travel
Medical Information
Existing Medical Conditions
Medications Taken
Allergies
Immunizations (relevant to destination)
Travel Medical Insurance Provider
Emergency Contact Name
Emergency Contact Phone
Declaration
I declare that the information provided is accurate and complete.
Signature
Date