Medical Report Form For Seafarers Serving On Ilo

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DEPARTMENT
REPUBLIC OF CYPRUS
MINISTRY OF
OF MERCHANT SHIPPING
COMMUNICATIONS AND WORKS
LEMESOS
MEDICAL REPORT FORM FOR SEAFARERS SERVING ON SHIPS UNDER
THE FLAG OF CYPRUS
For completion by ship’s doctor or master and hospital or doctor ashore, in cases of
illness or injury affecting seafarers.
Note: Copies of this form should be provided for the seafarers medical records, ship’s
master (or his representatives) and hospital/doctor ashore.
For completion by ship’s
Date: ____________________________________
master:
Patient’s Name: __________________________________________________________
Date of Birth _________________ Name of ship: ______________________________
Nationality _________________ Shipowner: ________________________________
Name of ship’s
Seafarers
representative/agent
Cyprus SB no: _______________
on shore: _________________________________
Address and tel. no
of ship’s representative
Shipboard
position held: ________________
/agent on shore: ____________________________
Details of illness or injury. Treatment received
On board ship (enclose attachments if necessary) ________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Date of onset of illness: _______________
Date injury occurred:_________________
For completion by hospital or examining doctor on shore

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