Medical Release Form

Traveler Medical Information
Personal Physician*
Office Number*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Last Tetanus Shot*
MM slash DD slash YYYY
Allergies to Medicine or Food
Existing Medical Conditions
Physical Impairments
Current Medications
Insurance Information
Health Insurance Company*
Policy Number*
Group Number*
Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
Agent Name
Phone Number
Primary Insurance Holder*
Whose name is the insurance under? This is often self, spouse, or parent.
Relationship*
What is the primary holder's relationship to you? Often Self, Spouse, or Parent.
Travelers are strongly encouraged to consult with their physician prior to travel to review vaccination and medical recommendations prior to the trip.

Emergency Contact Information