Coast Guard Medical Clearance Form

Applicant Full Name

First NameLast Name

Date of Birth

Date

Contact Information (Phone Number)

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Have you ever been diagnosed with any of the following conditions? (Select all that apply)

Please list any medications you are currently taking (include dosage and frequency)

Do you have any allergies?

Yes (please specify)

Emergency Contact Name and Relationship

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Medical Professional's Name

Medical Professional's Contact Information (Phone or Email)

Medical Professional's Evaluation: Based on my examination, the applicant is:

Medically fit with restrictions (please specify)

Applicant Signature

Medical Professional Signature