Medical Information Form
(confidential when complete) All information provided by you in this form will be kept confidential by TAC. Due to adventurous nature of all our trips and expeditions it is essential for us to collect information about your medical status and fitness to ensure a safe experience for you, appropriate to your level of physical fitness. If we have any question about your capability to complete the program, we will call and discuss it with you. Please complete this Form, including the details of your medical insurance coverage, and return it to our office together with the Booking Form and Indemnity Agreement.
1. Your Personal data
2. Person to be notified in case of illness or injury (Please give full name and address)
Name ______________________________________ Relationship _______________________
Street__________________________ City_____________ Postal Code________
Country ________________________
Daytime Phone ______________________ Evening Phone ______________________
Please ensure that the above person will be contactable for the duration of your trip
3. Medical Insurance
EACH PARTICIPANT IS RESPONSIBLE FOR ANY MEDICAL EXPENSES AND SHOULD BE COVERED BY THEIR OWN SICKNESS AND ACCIDENT INSURANCE.
Do you have medical insurance coverage? Yes___ No___
Name of Insurance Company ______________________ Policy Number_________
Address _______________________________________________________________
Phone__________________
4. Please provide details of any illness or medical conditions you have at present.
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5. Please provide details and dates of any illnesses or medical conditions which you have had in the past.
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6. What medications are you currently taking? Please give full details and include dose and frequency taken.
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7. Do you have any physical limitations or disabilities? If yes, please give details:
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8. Do you have any drug allergies? If yes, please explain which ones and give precise details of the effects:
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8. Have you ever had frostbite or associated cold related injuries before? If yes, please give details:
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9. Please, evaluate your health:
10. Please evaluate your physical fitness:
Consent is hereby given for any emergency anesthesia, operation, hospitalization or other treatment that might become necessary. The information provided above is a complete and accurate statement of the physical and psychological factors, which may affect my participation on a TAC expedition. I realize that failure to disclose such information could result in serious harm to fellow participants and myself and agree to indemnify and hold TAC harmless if all relevant information is not disclosed.
Signed: ………………………………………… Date: …………………………… |
