Travel Medical Certificate Form

Travel Medical Certificate Form
Complete this form to certify your fitness for travel. Please ensure all information is accurate and up to date.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Travel Destination Country
Departure Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Return Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you currently have any of the following symptoms?
Do you have any pre-existing medical conditions?
If yes, please specify your medical conditions
Are you currently taking any medication?
If yes, please list your current medications
Name of Certifying Healthcare Provider
Contact Number of Healthcare Provider
Please enter a valid phone number.Format: (000) 000-0000.
Date of Medical Evaluation
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Traveler
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