Fillable Medical Information Form printable pdf download

Medical Information Form

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Complete Medical Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Medical Information Form

The information provided on this form will be held in the strictest confidence and will not be seen

by any person or agency (except the trip leader) except in the event of a medical emergency. The

form must be completed by all UW‐Platteville students, faculty/staff participating in a university

sponsored overnight fieldtrip. No later than one week after the trip is over, the Medical

Information Form must be returned to each trip participant. If this is not possible or if the

participant does not wish to receive the form, then the faculty/staff must immediately destroy the

form.

Name of Trip Participant:_____________________________________________________________________

Gender: ___________ Date of Birth: ________________________

*******************************************************************************************

Name of personal physician: ________________________________________________________________

Address of personal physician: ______________________________________________________________

________________________________________________________________________________________

Phone number of personal physician: ________________________________

******************************************************************************************

In case of emergency, contact: ______________________________________________________________

Relationship of contact person: ____________________________

Address of contact person: ________________________________________________________________

_______________________________________________________________________________________

Phone number of contact person: ______________________________

*******************************************************************************************

Health Insurance Company: __________________________________________________________________

Health Insurance Group Number: ___________________ Subscriber Number: ________________________

Health Insurance Company Address: ___________________________________________________________

_________________________________________________________________________________________

Health Insurance Company Phone Number: _____________________________________________________

Medical Information Form

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