Pre-Trip Medical Form

Please note : The form will not send until all the required information is filled out, so if you click on the send button and nothing happens, simply check through the boxes to see what is missing. If you do not have any information for a category simply write nil. Make sure you read through the Terms and Conditions carefully.

Pre Trip Medical Form

Name *

Email Address *

Age at trip *

Daytime phone *

Mobile phone *

Postal address *

Occupation *

Which trip have you booked (eg. 5 day heaphy) *

Depatrure date *

Pre existing medical conditions *

Please list all medications currently being used *

Please list any and all allergies *

(e.g. medications, pollens, food, bee or wasp stings etc)

Dietary needs & preferences *

(e.g None, Omnivore, Vegetarian, LactoVege, Vegan, Gluten free, Atkins, Low fat, Dairy Free, No Nuts)

Emergency contact name *

Emergency contact phone (daytime) *

Emergency contact phone (mobile) *

Accept Terms *

I agree to the Southern Wilderness New Zealand Limited Safety Terms & Customer Declaration See our terms and conditions here

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