Medical Form

Medical

1. Traveller Details

Full Name:

Date of Birth (DD/MM/YYYY):

Passport Number:

Nationality:

Email Address:

Contact Number:

Tour Name:

Tour Start Date:

2. Emergency Contact

Full Name:

Relationship to Traveller:

Phone Number (incl. country code):

3. Medical Information

Do you have any existing medical conditions? (Yes/No)
If yes, please provide details:

Are you currently taking any prescription medication? (Yes/No) If yes, please list all medications and dosages:

Do you suffer from allergies? (e.g., food, medication, insects) If yes, list them:

Have you had any recent surgeries or hospitalisations?

Do you have any physical limitations or mobility concerns?

Do you use any medical equipment (e.g., CPAP, insulin kit)?

Have you received all recommended vaccinations for your destination? (Yes/No) If no, please explain:

4. Fitness to Travel Declaration

Have you been advised by a doctor that you are fit to travel and participate in active tours?

5. Pregnancy (if applicable)

Are you currently pregnant? (Yes/No)

If yes, how many weeks pregnant will you be during travel?

Are there any activities you should avoid for health reasons?

6. Optional – Physician’s Medical Clearance

Physician’s Name:

Medical License Number:

7. Traveller Declaration & Consent

I confirm that the information I have provided is true and accurate to the best of my knowledge. I understand that withholding relevant medical details may result in removal from the tour without refund. I consent to Anteros Travel collecting and using this information to ensure my health and safety throughout the trip.

Signature

Date

Medical Form

1. Traveller Details

2. Emergency Contact

3. Medical Information

4. Fitness to Travel Declaration

5. Pregnancy (if applicable)

6. Optional – Physician’s Medical Clearance

7. Traveller Declaration & Consent

where we are now

Contact Details

Email Address

Phone

Address

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Medical Form

1. Traveller Details

2. Emergency Contact

3. Medical Information

4. Fitness to Travel Declaration

5. Pregnancy (if applicable)

6. Optional – Physician’s Medical Clearance

7. Traveller Declaration & Consent

where we are now

Contact Details ​

Email Address

Phone

Address

Follow Us​

NEWSLETTER

Contact Details

Follow Us