Medical Form – Motorcoach Tours – Anderson Travel and Tours

Guest Name

First

Middle

Last

Cell Phone :

(phone you will have with you on the tour)

Email:

Birthdate:

Emergency Contact's Name:

“DO NOT” LIST YOUR SPOUSE OR PARTNER who will be traveling with you as an emergency contact! This MUST be a contact who will not be on this tour!

Emergency Contact's Relationship to You:

(spouse, child, other relative, guardian, friend, etc.)

Emergency Contact's Cell Phone:

Emergency Contact's Home/Work Phone (if applicable):

Emergency Contact's Email:

Emergency Contact's Address:

Address Line 1

Address Line 2

City

State

Zip Code

List health conditions, recent surgeries, medical devices, medications, etc. that we would need to alert an ER of in case of emergency:

EXAMPLES: pacemaker, ostomy, asthma, diabetes-insulin, epilepsy, cancer, recent surgery, bleeding disorder, taking blood thinner, etc.

List any medication, food or other major allergies"

EXAMPLES: food allergies, drug allergies, latex allergy, other allergies, insect stings, or anything else that could cause an allergic reaction or lead to anaphylactic shock.

Do you have a DNR (Do-not-resuscitate) Order?

YES
NO

(In case of emergency)

Name of your Health Insurance Provider:

Phone Number of Health Insurance Provider:

(look on the back of your insurance card)

Travel Insurance:

I purchased the Travel Insured “Travel Confident” Plan through the link for this tour .
I purchased another Travel Insurance plan.
I did not purchase travel insurance.

NOTE: All required fields with a red asterisk beside them must be completed before this form will submit.

I have completed all required fields above.