Anna Landauer - Confidential Medical Form

Anna Landauer - Confidential Medical Form

Medical form used for emergencies. Form Preview
Anna Landauer - Confidential Medical Form
  • Anna Landauer - Confidential Medical Form

  • Please submit this form at least two weeks prior to the trip start date.

    I ask for this information so that I’ll know in advance of special medical conditions you may have, rather than learning about them in a crisis. Also, in the event of a serious injury or illness, this form provides emergency medical personnel with a useful medical history.

    This form is confidential. It will be seen only by myself, my assistant, medical personnel, or others who know and understand its confidential nature. The form will be retained for a period of time following the trip, after which it will be permanently deleted. If you choose not to go on the trip, this form will be deleted immediately.

    Please contact me if you have any questions regarding the information on this form.

    Thank you!

  • GENERAL INFORMATION

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  • Emergency Contact:

  • If this person is unavailable, please notify: