SEASIDE MARINE MEDICAL KIT INFORMATION REQUEST FORM Please complete and return with copy of the Vessel Documentation to: SEASIDE MARINE INTERNATIONAL DRUG COMPANY 599 W. 7th STREET SAN PEDRO, CA. 90731 Ph: 800-832-4363 Fax: 800-548-5527 VESSEL * NAME__________________________________________________________________________________ * CF NUMBER/DOCUMENTATION NUMBER _______________________________________________________ * HOME PORT_____________________________________________________________________________ * PHONE/FAX ____________________________________________________________________________ * EMAIL ________________________________________________________________________________ OWNER * NAME _________________________________________________________________________________ * ADDRESS ______________________________________________________________________________ * CITY/STATE/ZIP _______________________________________________________________________ * PHONE ________________________________________________________________________________ * FAX __________________________________________________________________________________ * EMAIL ________________________________________________________________________________ * MEDICAL TRAINING _____________________________________________________________________ ________________________________________________________________________________________ CAPTAIN * NAME __________________________________________________________________________________ * ADDRESS _______________________________________________________________________________ * CITY/STATE/ZIP_________________________________________________________________________ * PHONE _________________________________________________________________________________ * FAX ___________________________________________________________________________________ * EMAIL _________________________________________________________________________________ * MEDICAL TRAINING ______________________________________________________________________ _________________________________________________________________________________________ PORT(S) OF DESTINATION __________________________________________________________________ LENGTH OF VOYAGE ________________________________________________________________________ MEDICAL NEEDS * MEDICAL SERVICE OR PHYSICAN TO BE CONTACTED IN AN EMERGENCY NAME ___________________________________________________________________________ PHONE __________________________________________________________________________ * AVERAGE NUMBER OF CREW/PASSENGERS ABOARD ___________________ * ANY KNOW ALLERGIES OF CREW/PASSENGERS ________________________________________________ ________________________________________________________________________________________ * ANY SPECIAL MEDICAL CONDITIONS/REQUIREMENTS___________________________________________ ________________________________________________________________________________________ ***** SEASIDE MARINE REQUESTS THAT NO MEDICATIONS BE DISPENSED WITHOUT THE APPROVAL OF A MEDICAL PROFESSIONAL. PLEASE CONTACT MARITIME HEALTH SERVICES FOR EMERGENCY MEDICAL ASSITANCES OR ADVICE, 24 HOURS. Ph: 206-781-8770 / Fax 206-781-8771 / Telex 6838206 MHS UW / www.shipmd@globalmd.net