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.