Medical Treatment & Document Form

Medical Treatment & Information Form

Yoga, Hiking & Healing Retreat - Greece, 2019
Dear Retreaters! Please fill out this very important form regarding your medical profile and sign the Treatment Authorization section.

NOTE: You will sign this form twice - once with your physical signature and once with Adobe Sign
DateTime
Your Name*

First NameLast Name
Your Email*
example@example.com
Please enter your INCOMING flight details to IOA (EG "Olympic 166, 7/14, 10:30am")
Please enter your OUTGOING flight details from IOA (EG "Olympic 166, 7/20, 12pm")
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship

Spouse/PartnerParentSiblingFriendOther
Emergency Contact Phone (Cell preferred)*

Area CodePhone Number
Primary Care Physician Name (optional, but recommended if available)

First NameLast Name
Primary Care Physician Phone (optional, but recommended if available)

Area CodePhone Number
Please enter Travel Insurance Company & Policy Number
Or upload the policy confirmation document (preferred)

Browse Files

Cancelof
Please list any surgeries or medical treatments within the last two years. (If none, type 'NONE')*
Please list any allergies. (If none, type 'NONE')*
Please list any dietary restrictions. Please be specific! (if none, type 'NONE')*
Please list any medications you are currently taking. (If none, type 'NONE')*
Please list any other conditions a physician in a foreign country should be aware of (If none, type 'NONE'). *
In the event of a medical emergency I consent to and authorize medical or hospital treatment, which in the best judgement of a licensed physician is deemed advisable, appropriate and/or necessary for my health and safety. *

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Medical Treatment & Information Form