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Confidential Medical Information

A Medical information form is required of all people joining any expedition. You can either download the form and send via the mail, or fill out the online form below.

Download the form

FHE Medical History Form – Please download, fill out, and send the form back to:

Garrett Cooper
10516 Bastille Ln. 
Apt 203
Orlando Fl 32836

Online Submission

Fill the form out below:

* = required

Name*
Address*
City*

State*

Zip*

Home Phone*
Cell Phone
Email Address*

Date of Birth*

Do you have allergic reactions to any food, drugs, insects, plants, or other substances?

Describe your allergy/allergies:
Do you carry an Epi-Pen, auto injector, medications, or devices?
If no allergies exist, initial here:

Are you presently under the care of a physician?

Please list and explain any medical conditions

Physician’s Name

Physician’s Phone:

If no medical conditions exist, initial here:

Are you presently taking any prescription medications?

What type and for what?

In Case of Emergency, Notify:

Contact's Name

Contact’s Phone

Contact’s relationship to you