Confidential Medical Information

The submission of this completed form constitutes an agreement between you and Icetrek Expeditions that all of the information provided is true and not intended to mislead Icetrek or misrepresent you. All fields are mandatory. Write No or NONE if any medical conditions don't apply.

Are you taking any medication? If so what, dosage and how often?

Have you had any surgeries? If so, what and when?

If so what is your typical reading?

What is your daily or weekly fitness regime?

Describe your dietary dislikes, intolerances and/or allergies

Name and phone number

Name and phone number

List your insurer, policy number and their emergency phone number.

Emergency Medical Evacuation (Medevac) insurance is required for all North Pole and South Pole/Antarctic trips. Medevac insurance is not mandatory for our other trips however we strongly recommend it as an inclusion in your medical/travel policy.

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