Doctor Registration

We need you to complete the following form accurately so we can book flights and make all the other arrangements for your expedition asap.

Forename(s) as Per Passport*
Surname as Per Passport*
Email*
Phone*
Passport Number*
Nationality*
Country of Birth*
Place of Issue*
Date of Issue*
DD slash MM slash YYYY
Date of Expiry*
DD slash MM slash YYYY
Date of Birth*
DD slash MM slash YYYY
Medical Council/GMC Number*
Gender*
Next of Kin Name*
Next of Kin Phone Number*
What is Their Relationship with You?*
Do you have any medical allergies, illnesses, injuries or are you currently taking any medication?*
We need this information in the case that you fall ill and require first aid treatment from the expedition leader.
Do you have any Dietary Restrictions?*
*
- . I have read the expedition itinerary and to the best of my knowledge I am fit and healthy enough to partake in the entirety of this expedition.
We highly recommend obtaining your travel insurance with Trailfinders. To obtain a quote and book insurance with Trailfinders please click here.*
- . I understand I need to obtain travel insurance which covers me for this expedition.
We highly recommend obtaining your travel insurance with Trailfinders. To obtain a quote and book insurance with Trailfinders please click here.
Please contact your medical indemnity insurance provider asap to obtain confirmation that they will cover you.*
- . I confirm it is wholly my responsibility to obtain and pay for medical indemnity insurance which covers me for this expedition.
Please contact your medical indemnity insurance provider asap to obtain confirmation that they will cover you.
*
- . I have read the doctor file and I am clear on what the expedition doctor role entails and what is expected of me.
*
- . I confirm I am familiar with altitude medicine and I have read and understood the CDC paper on Altitude Illness.
*
- . I confirm I am familiar with all of the medical equipment and medication supplied by Earth’s Edge including the correct dosages, potential side effects and reactions. I confirm that I will research the destination myself and I will carry any additional medicines I feel are needed over and above what is supplied by Earth’s Edge. I confirm I will check and make sure that the medical equipment and medication supplied by Earth’s Edge is present and in working order prior to departure. It is exclusively my responsibility to decide when and to whom to give medical care to on the expedition.

Doctor Registration

Doctor Registration

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