HTCNE HEALTH FORM
REMEMBER TO HIT SUBMIT AT THE END OF THIS PAGE
What trip are you traveling with:
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Ica Peru / Ransom / April 12-20, 2024
Santa Marta Colombia / Foglietti / May 18-25, 2024
Mwanza Tanzania / Barrett Dougherty / May 18-26, 2024
Mwanza Tanzania / Abraham Rasamny / July 8-14, 2024
Nairobi Kenya / Keiser Dental / Oct 24 - Nov 2, 2024
First Name
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Last Name
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Birth Date
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Please select a month
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Month
Please select a day
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Day
Please select a year
2024
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Year
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
1
2
3
4
Additional information regarding your medications, if needed
Have you been fully vaccinated against Covid-19?
YES
NO
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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