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.

Name

General health

Height

Weight

Do you have any current or recurring medical problems?

Are you taking any medication?

Have you had any surgeries?

Do you have any food, medical or other allergies?

Do you suffer unusually from Reynaud's Syndrome, chillblains, previous frostbite, sleep coldly.

Do you have problems with vision or hearing?

Do you have high blood pressure?

Do you have heart murmurs, episodes of irregular heartbeat, shortness of breath or chest pain on exertion?

Do you have asthma?

Do you have any other respiratory or cardio-vascular problems?

Do you suffer from altitude ailments?

Do you have any mental health issues?

Fitness

Do you require a special diet?

Are you over 60?

NoYes. Please upload a letter from your doctor approving your participation in activities that may include exposure to extreme cold and/or altitude equivalent to 3500m.

Upload Letter

Emergency Contact

Doctor contact details

Emergency Medical Evacuation Insurance

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 recommend that you have personal medical cover.

Options

I am organising my own emergency medical evacuation insuranceI am doing a Svalbard, Greenland or Australia trip (evacuation insurance not required but we recommend medical and emergency medical evacuation cover)

Disclosure

I realise that failure to disclose relevant information could result in serious harm to fellow participants and myself and agree to indemnify and hold Icetrek harmless if all relevant information is not disclosed

Statement

The information provided above is a complete and accurate statement of the physical and psychological factors which may affect my participation on an Icetrek expedition or tour.

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Confidential Medical Information