Seaside Marine Medical Information Request Form
Vessel
Name
CF Number
Documentation Number
Home Port
Phone
Fax
Email
Owner
Name
Address
City
State
Zip
Phone
Email
Medical Training
Captain
Name
Address
City
State
Zip
Phone
Fax
Email
Medical Training
Port(s) of Destination
Length of Voyage
Medical Needs
Name of medical Service or physician to be contacted in an emergency
Phone
Average number of crew/passengers aboard
Any known 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 assistance or advice 24 hours.
Ph: 206-781-8770 / Fax 206-781-8771 / Telex 6838206 MHS UW / www.shipmd@globalmd.net