Medical Tourism Visitor Medical Information Declaration Form
Full Name
Passport Number
Nationality
Date of Birth
Contact Number
Email Address
Home Address
Purpose of Visit (Medical Procedure)
Hospital/Clinic Name (Destination)
Travel Dates
Arrival
Departure
Emergency Contact Name
Relationship
Emergency Contact Number
Existing Medical Conditions
Allergies
Medications
Recent Surgeries/Treatments
Vaccination History
Physician's Name & Contact
Insurance Provider
Policy Number
Declaration & Consent
I hereby declare that the above information is accurate and complete to the best of my knowledge.