Medical Form Medical Declaration & Insurance Waiver Form
General Warnings
No sophisticated medical facilities are available in the Andean region. This Tour / Trek is intended for persons in reasonably good health and fitness.
Passengers who are not fit for long trips for any reason, who have a serious heart or other health condition, knee problems, or who are more than 18 weeks pregnant, should not participate in a Trek or multi-day hike, but can participate in a non-trekking Tour. Should any such condition become apparent, we reserve the right to decline to accept or to retain you at any time during the trip.
In addition, you are advised to carry your own regular medication as it may not be available in Peru. We recommend travelling with this medication in your carry-on in the event of misplaced luggage by the airline; syringes will not be allowed in carry-on bags. Clients are further advised that medical evacuation, if available, is expensive, and we strongly recommend that you have medical insurance that will reimburse you for this cost.
Important : We do not require these forms to be completed prior to booking, but if you make a booking and your doctor completes Part III indicating that you are unfit for the trek you have selected, Apus Peru reserves the right to not accept you for the trek. Please note that in this case your deposit is non-refundable.
Part I: Health Statement & Insurance Waiver 1. General health & fitness
I attest that I am in good general health, of excellent fitness, and am capable of performing normal activities on this Trek or Tour. If not, I have or will embark on a fitness program designed to prepare me for a high-altitude trek. This might include walking 5-8h per day in hilly terrain or up and down stairs, if there are no hills where I live.
2. Trek information
I have read and understood the information on the website describing the Trek or Tour I have booked, taking particular note of the difficulty level and hours of walking per day. Remember – no trek in the Andes is easy!
3. Children
For children and youth under 16, parents or guardians confirm that the child has the resilience and stamina to manage the trek difficulty. Parents or guardians further confirm that they will have taken the child for back-to-back days hiking at least 5h per day, camping overnight in between.
4. Acclimatization
I understand that high altitude affects people differently, but may increase heart rate or blood pressure, cause shortness of breath, headaches, dizziness, general unease and/or loss of appetite. I understand that sufficient acclimatization prior to beginning any trek is essential and that the minimum acclimatisation period for all treks is 2-3 full days (48-72 hrs), but this is less than ideal.
5. Medical conditions and treatment
I understand that this Trek or Tour will take me far from the nearest medical facility and that all trip members must be self-sufficient. With that understanding, I certify that I have not been recently treated for, nor am I aware of, any physical or other condition or disability that would create an impediment to myself or other members of the group completing the trip enjoyably.
6. Comprehensive Travel Insurance
Apus Peru strongly recommends that you take out comprehensive travel insurance that includes coverage for trip interruption or cancellation, as well as a medical component, and specifically covers adventure travel. Read more about why comprehensive travel insurance is essential in our blog.
Have you taken out travel insurance?
- Select - Yes No Not yet, but I plan to
We recommend booking travel insurance now as a significant value of travel insurance is being covered for life’s unexpected turns from the time of booking through to the time of departure , as well as during the course of your trip.
Please confirm that you understand that you are responsible for all medical, cancellation or change of route costs.
- Select - I understand.
If you do not have insurance, please complete the following waiver:
I recognize the risks of participating in a tour or trek with Apus Peru Adventure Travel Specialists and assume responsibility for all associated costs in the event of trip interruption or cancellation, in accordance with Apus Peru Adventure Travel Specialists, and assume responsibility for all associated costs in the event of trip interruption or cancellation according to Apus Peru's Booking Conditions
Part II: Medical Information (Main Traveller Information)
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Are you filling this form out for more than one person (child, other family member, or friend)?
Part II: Medical Information (Traveller 2) Please also fill in the medical information for traveller 2 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 3) Please also fill in the medical information for traveller 3 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 4) Please also fill in the medical information for traveller 4 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 5) Please also fill in the medical information for traveller 5 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 6) Please also fill in the medical information for traveller 6 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 7) Please also fill in the medical information for traveller 7 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 8) Please also fill in the medical information for traveller 8 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 9) Please also fill in the medical information for traveller 9 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 10) Please also fill in the medical information for traveller 10 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 11) Please also fill in the medical information for traveller 11 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part II: Medical Information (Traveller 12) Please also fill in the medical information for traveller 12 of your group.
Medical & Health Information
Evaluate your general health
- Select one - Fair Good Excellent
Do you have any of the following conditions (check all that apply):
*If you suffer from asthma, it is essential that you visit your doctor prior to your trip. During your Tour / Trek you will be at high altitudes, in areas that can be very cold, very dry or very humid, and where animals are present. Please ensure that your doctor is aware of this and that you travel with the appropriate medication for your condition.
If you checked any of the above, please provide more details, including all medications you are currently takin, including dosages and contraindications.
Are you pregnant?
- Select - Yes No
Part III: Emergency Contact Information
Please provide the contact details of the person we should reach out to in case of an emergency.
Part IV: Medical Advisor’s Opinion If you meet any of the criteria listed below, you will be required to have your personal physician review your itinerary and sign a letter (which we will provide) confirming your ability to participate in the trek.
You will also be required to obtain travel medical insurance and be accompanied by a trekking companion on the trek at all times who will trek by your side and be familiar with any medicines required in case of an emergency.
Please select all of the conditions which apply to you
Thank you for confirming that one or more of the listed medical conditions applies to you. Your Travel Consultant will provide you with a letter to review with your doctor.
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