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! This MUST be a contact who will not be on this tour/motorcoach!

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, etc. 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 allergies or other allergies:

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

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

YES
NO

(In case of emergency)

Name of your Primary Care Physician:

Phone number of your Primary Care Physician:

Name of your Health Insurance Provider:

Phone Number of Health Insurance Provider:

(look on the back of your insurance card)

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.