Medical release & consent

Strasburg, CO 80136 Medical Release & Consent
This must be filled out and signed by the traveler’s Physician. Please print clearly. Special Vacations must have this original form along with copy
of medical insurance card.

Traveler’s Name: ______________________________________ ___________________________________________________________ _______________________________________________________________________ Will traveler need assistance with meds on trip? ___________________________________________________________ ________________________________________________________________________ If other explain:______________________________________________________ ________________________________________________________________________ Please check all boxes that may apply to traveler: Allergies
Drug allergies:____________________________________________________________ ________________________________________________________________________ Other allergies: ___________________________________________________________ ________________________________________________________________________ Strasburg, CO 80136 Medication or Doctor’s Med Sheet
Special instructions for Medications___________________________________________ ________________________________________________________________________ May take over the counter medications, if necessary If necessary, which medications may the traveler take? Please check all that apply. If Yes, explain _______________________________________________________ ________________________________________________________________________ Strasburg, CO 80136 Seizures and Authorization
Types of seizures _______________________ Date of last seizure ____/____/____ How often ______________ Duration _______ Minutes _______ Seconds ______ If Yes, please explain what precautions need to be taken to help prevent traveler from having a seizure, if at all possible, and what is their post seizure behavior? Please list any before and after procedures that need to be taken: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Comments:_______________________________________________________________ ________________________________________________________________________
I have examined and evaluated this client’s past and present health history. It is in
my opinion that this client is able to engage in a Special Vacations trip.

Any Limitations are as noted:_______________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____________________________________________________ ________________________________________ Phone
Special Vacations must have this original form along with copy of medical
insurance card. Please mail original form to:


Apm 7-8-201

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