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Customer Medical Information
Please fill out this form as accurately as possible. The information provided will be kept confidential, and will only be shared with trip leaders and in an emergency situation with medical personnel when and where appropriate.
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First & Last Name
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Phone Number
*
Your answer
Primary Insurance Company & Policy Number
*
If you do not have insurance that covers you abroad, please enter "N/A"
Your answer
Do you have any allergies?
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If so, list and explain what happens if exposed.
Your answer
Do you have any present/past medical conditions?
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Asthma, diabetes, heart conditions, seizures, joint problems, etc.
Your answer
Are you currently taking any medications?
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Prescription or over the counter. If so, please list.
Your answer
Do you have any dietary restrictions?
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If so, what are they?
Your answer
Emergency Contact Name & Phone Number
Your answer
Is there any additional information that we should have regarding your health/medical information for this trip?
Your answer
I affirm that the above information is accurate and free of omissions. I will inform Carpe Mundo of any changes in my health between now and the tour. I authorize Carpe Mundo representatives or designees to act on my behalf according to their judgment in an emergency requiring medical attention, including but not limited to treatment by medical care providers, and I will be responsible for any medical or other charges incurred. I have read, agree to, and understand these terms.
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