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 Beneficiary Name*
Relationship*
Secondary Beneficiary Name*
Relationship*
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