TU Treks - Medical Information

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My Information
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* Ex: 918-631-2516
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Emergency Information
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Medical Information

Are you covered by medical insurance?

  

Are you currently under a Physician's orders for medication or treatment?

  

Will you have these medications with you on any outing?

  

Are you allergic to insect stings, poison ivy, foods, drugs, or other things?

  

Please check any of the following conditions that pertain to you:

If you answered yes to any of the above questions or checked a condition from the above list, please list the medications, dosage, and the frequency with which these are taken; describe specific allergies, your symptoms, the frequency of occurrence, how you care for the condition and how this condition restricts your activity in any way; and/or describe all information, including specific symptoms, how long the symptom/condition lasts, frequency of occurrence, how you care for symptom/condition, and how the condition restricts your activity in any way.

Authorization

Authorization for Emergency Medical Care: Should an accident occur, I hereby give permission to the physician selected by The University of Tulsa Get Outside Staff to hospitalize and/or secure proper medical treatment for me except as noted below. I agree to hold only myself liable for these noted exceptions.

*Please type full name
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