Medical Form

Please fill out the form to help us better serve you in the event of an emergency. Fields marked with an * are mandatory. Thank you for your assistance.
Name*
First Middle Last
Please enter you full name as it appears in your PASSPORT
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

No PO boxes
Phone*
Preferably mobile phone
Email Address*
Birthdate*
DD slash MM slash YYYY

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Do You Wear Contacts?*
- Yes
- No
Do You Wear Dentures?*
- Yes
- No
Blood Type
Please list any medical condition(s)/disease(s)/allergies/dietary restrictions*
If none, please write "None"
Please list all prescription medications and dosages you are currently using*
If none, please write "None"
Please list any medical equipment you will be bringing with you*
If none, please write "None"
Date of Last Tetanus Shot
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Tetanus booster. After the initial tetanus series, booster shots are recommended every 10 years.
Date of Last Typhoid Shot
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Typhiod vaccination.
Date of Last Hepatitis A Shot
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Hepatitis A vaccine.
Date of Hepatitis B Shot 1
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Hepatitis B vaccine.
Date of Last Hepatitis B Shot 2
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Hepatitis B vaccine.
Date of Last Hepatitis B Shot 3
MM slash DD slash YYYY

We strongly urge all guests to have an up-to-date Hepatitis B vaccine.

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Required Coverage: • Accident & Sickness Medical Expense Coverage (minimum $100,000 USD) • Emergency Evacuation & Repatriation of Remains (minimum $200,000 USD) • Accidental Death / Dismemberment • Trip Cancellation Coverage
Choose one*
- My Trip and Travel Medical Insurance policies are in a combined policy
- My Trip and Travel Medical Insurance policies are in separate policies
If Trip and Travel Medical Insurance policies are in a combined policy please submit the same details in both fields.
Upload a PDF Copy of your Travel Medical Insurance*
Drop files here or

Accepted file types: pdf, Max. file size: 128 MB.
Travel Medical Insurance Company*
Travel Medical Insurance Policy Number*
Date of Travel Medical Insurance Purchase*
MM slash DD slash YYYY
Travel Medical Insurance Phone*
Trip Insurance
Travel Trip Insurance Company*
Travel Trip Insurance Policy Number*
Travel Trip Insurance Phone*
Date of Trip Travel Insurance Purchase*
MM slash DD slash YYYY
Upload a PDF Copy of your Travel Trip Insurance*
Drop files here or

Accepted file types: pdf, Max. file size: 128 MB.
If you have multiple files, please uload all of them.

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I have voluntarily provided the above contact information and authorize Discovery Photo Tours, and its representatives to contact any of the above on my behalf in the event of an emergency. I understand and agree that it is not the responsibility of Discovery Photo Tours, to cover any medical expenses I may incur while on this trip; however, the information I have submitted can help provide me with the proper medical care in the event it is needed. By signing below I am agreeing to the Discovery Photo Tours terms of service and to be financially responsible for the expense of any medications, medical services and/or procedures which may be incurred on this trip.

Please sign, date, and return this form as quickly as possible to assist us in administrating this trip. Your signature acknowledges to us that you are submitting complete and accurate information so that we may better serve you.
I have read, consent and agree to the Discovery Photo Tours Terms of Service*
- Yes
https://www.discoveryphototours.com/terms-of-services/
Signature*
TODAY's DATE
09/26/2023
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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Trip Insurance