Tier 1 — Destination Medical Guide Intake Form

Please provide accurate and complete information. This intake is used to generate a destination-specific medical guide covering healthcare facilities, pharmacies, laboratory services, and baseline logistics relevant to your medical condition. No consultation call is included at this tier. All information is kept strictly confidential.

1 Personal Information

Basic contact details for report delivery.

First Name *

Last Name *

Email Address *

Phone Number

Date of Birth *

Gender

Country of Residence *

2 Travel Details

Where and when you plan to travel.

Destination Country / Region *

Approximate Departure Date *

Approximate Return Date

Trip Duration (days)

Cities / Areas You Plan to Visit

Accommodation Type

3 Medical Profile

Your current medical conditions and treatment. This is critical for an accurate report.

Primary Medical Condition(s) *

Current Medications * (include dosages if known)

Are you immunocompromised? *

Allergies (medications, foods, environmental)

Surgical History (major procedures and approximate dates)

Do you require any of the following during travel? (check all that apply)

IV fluid administration Laboratory monitoring (e.g., tacrolimus levels, CMV viral load) Supplemental oxygen Dialysis access Specialty pharmacy access Refrigerated medication storage Other (describe below)

Other Medical Needs or Notes

4 Current Care Team

So we can align our report with your existing medical team if needed.

Primary Physician / Specialist Name

Hospital / Institution

Physician Contact (email or phone — optional)

5 Specific Concerns

Help us focus the report on what matters most to you.

What are your top concerns about this trip? (check all that apply)

Infectious disease exposure Hospital / healthcare quality Medication access and availability Lab testing availability Medical evacuation options Travel medical insurance Vaccine requirements and contraindications Food and water safety

Anything else you would like us to address?

What Happens Next: After submission, your intake will be reviewed and a Destination Medical Guide will be delivered to your email within 3–5 business days. This report provides information only. If you require consultation, vetted contacts, or emergency protocols, consider upgrading to Tier 2 ($5,000) or Tier 3 (est. $15,000+).

Disclaimer: This service provides health-related travel information and does not constitute medical advice, diagnosis, or treatment. Always consult your own physician before making travel decisions. Any actions taken based on the report are at your own discretion and cost.

I confirm that the information provided is accurate to the best of my knowledge. * I understand this is an information-only service and does not constitute medical advice. * I consent to my information being used solely for the purpose of generating this report. *

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