Cooking Vacations in Italy
Medical Form for Culture Discovery Vacations Tours, Vacations & Classes
General Information
The information you provide to CDV in this form will be held in the strictest confidence, and will be used only to the extent necessary to provide necessary emergency medical care and/or evaluate fitness for travel. Please note that this may include transmitting your data overseas to any countries to which you may be visiting, but only as required. The collection, use, and disclosure of your personal information is governed by the CDV Privacy Policy, which can be accessed any time at https://www.culturediscovery.com/docs/privacy-policy.cfm
Who should complete this form?
All travelers must complete sections ‘A’, “B”, and “C”’. If you have indicated that you have a pre-existing medical condition you are required to complete section ‘D’ also. The more information CDV has, the more we may assist in the unlikely event of an emergency or provide other medical assistance.
Please note CDV will assess the information contained in this form, and reserve the right to ask for a physician assessment for any guest.
You should always consult with your physician and anyone else familiar with your medical history and needs before embarking on any travel. Please ensure that you have confirmed with a medical professional that you are medically fit to embark on the travel you have booked.
Why do I need to complete this form?
Our vacations may travel to areas where limited medical facilities exist. A medical emergency situation is extremely unlikely; however, should it arise we are armed with the necessary information to help you. Generally, our vacations are intended for travelers in reasonably good health for their safety, along with that of their fellow travelers.
You must provide complete, accurate, and up-to-date information on this form in order to allow CDV to safely accommodate you. If you do not disclose a condition, infirmity, injury, or ailment herein and are subsequently deemed to be unfit for travel due in whole or in part to such condition, infirmity, injury or ailment, CDV shall have the right to remove you from the tour with no refund or compensation payable. If there are any changes to your physical/medical condition or otherwise to your responses below after your submission of the form to CDV, you must notify CDV immediately of that change. CDV reserves the right to request an up-to-date certification from a licensed physician in the event of such a change. If the information contained on this form is found to not be accurate as of your date of travel and you have not provided CDV with notice of such change, you may be removed from the vacation with no refund or compensation payable. Information provided in this form must be supplied at maximum 12 months prior to first date of travel.
What happens if I don’t complete this form?
In the event you have made a booking with CDV and subsequently are unable or refuse to complete this medical form for any reason by the final payment date as specified in our terms of service, CDV reserves the right to consider your booking cancelled as of that day and applicable cancellation penalties will apply.
How do I complete this form?
It is very important for your own health and safety that you complete all questions fully and truthfully. In the event of a medical emergency, the information you have provided could be crucial. All guests must complete, and return sections ‘A’, ‘B’, ‘C’ If guests answer yes to any question in section ‘B’, then use the printed version of this form and also complete section ‘D’. Part 1 of section ‘D’ must be completed by yourself, and Part 2 given to your medical practitioner to complete on your behalf. Each of you must then sign and return the entire document, sections ‘A’, ‘B’, ‘C’ & ‘D’.
Section A - General Information
Name: ____________________________________________________
Trip Name: ____________________________________________________
Booking Number: ____________________________________________________
Departure Date: ____________________________________________________
Section B - Medical Information
- During the last 5 years, have you suffered any significant illness, been hospitalized or
required regular care by a doctor?
☐ Yes ☐ No
If YES, please indicate reason: ____________________________________________________ - Have you ever had any of the following:
a) Tuberculosis, chronic bronchitis, emphysema or any other lung problems?
☐ Yes ☐ No
b) Asthma effects my everyday activities and/or I use medication or an inhaler regularly
☐ Yes ☐ No
c) High blood pressure, heart or respiratory problems, or rheumatic fever?
☐ Yes ☐ No
d) Gout or arthritis or any back, leg or foot problems?
☐ Yes ☐ No
e) Gastric or duodenal ulcer, colitis or intestinal trouble?
☐ Yes ☐ No
f) Epilepsy or fits of any kind?
☐ Yes ☐ No
g) Kidney or bladder disease?
☐ Yes ☐ No
h) Diabetes, cancer or tumor of any kind?
☐ Yes ☐ No - Do you have any physical limitations, handicaps or prosthesis? Do you have difficulty walking or use a device for mobility assistance such as crutches, cane or wheelchair?
☐ Yes ☐ No
If YES, please specify: ____________________________________________________ - Do you take medication or drugs related to a pre-existing medical condition?
☐ Yes ☐ No
If YES, please specify: ____________________________________________________ - Do you have any allergies, or reactions to any medication or drugs?
☐ Yes ☐ No
If YES, please specify: ____________________________________________________ - Are you pregnant?
☐ Yes ☐ No
If YES, how many weeks pregnant will you be at the time of travel? ____________________________________________________ - Are you affected by any other pre-existing medical conditions not listed above?
☐ Yes ☐ No
If YES, please specify: ____________________________________________________
Please Note:
If you indicated “YES” to any of the above questions (with the exception of question 2b or 5), you must fill in section ‘D’.
Section C - General Information
This section must be fully completed, please DO NOT OMIT any of the following details
Date of birth:____________________________________________________
Blood type (if unknown indicate ‘unknown’):____________________________________________________
Height:____________________________________________________
Weight:____________________________________________________
Insurance Provider:____________________________________________________
Insurance contact phone:____________________________________________________
Insurance policy number:____________________________________________________
Emergency contact name:____________________________________________________
Emergency contact phone:____________________________________________________
We ask you to complete this confidential medical report so that all due care may be provided. Some of our itineraries are intended for persons in reasonably good health and with full mobility. Guests who are not fit for long trips for any reason, including mobility issues, disability, heart or other health condition are advised not to join the tour, which would entail an unreasonable risk to your health and to the enjoyment of all those on the tour. Should any such condition become apparent, the Company reserves the right to decline or accept or retain you and any other guest at any time before or during the trip.
I attest I am in good general health, and capable of performing normal activities on this vacation. I further attest that I am capable of caring for myself during the vacation, and that I will not impede the progress of the vacation or the enjoyment of others in the group. I understand that I must be self-sufficient. With that understanding, I certify that I have not been recently treated for, nor am I aware of, any physical or other condition or disability that would create a hazard to myself or other members of the vacation group. I agree that should there be any change to the information I have given herein or to my physical or medical condition that I will notify CDV and, if requested, provide an up to date version of this completed form. I agree that any failure to provide full and complete medical information to CDV may result in the cancellation of my booking without further compensation payable to me for any loss.
I declare the answers to the above questions are true and complete. I agree to this information being made available to CDV.
____________________________________________
Guest Signature
____________________________________________
Date