2023 HTCNE HEALTH FORM
REMEMBER TO HIT SUBMIT AT THE END OF THIS PAGE
What trip are you traveling with:
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Tanzania / Abraham Barrett Team Aug 15-26, 2023
Santa Marta Colombia / Jacono Team Sept 30 - Oct 7, 2023
Amazon Region, Peru / Keiser Dental Team Oct 20 - 28, 2023
First Name
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Last Name
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Birth Date
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Please list any allergies you have below or simply type "None" if you have no allergies.
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Please list any Significant Medical Problems/Conditions below or simply type "None" if you have no significant problems or conditions.
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List any medications you are currently taking or type 'none' in one of the boxes. For example: Aspirin 250mg 3x daily
DRUG NAME
DOSE
FREQUENCY
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2
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Additional information regarding your medications, if needed
Have you been fully vaccinated against Covid-19?
YES
NO
Please upload a photo of your Covid-19 vaccination card
Browse Files
Cancel
of
Name of Your Physician
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Phone # of Your Physician
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Emergency Contact (First/Last Name)
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Relationship:
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Best contact number to reach this person
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