Exploring Exposure - Landscape Photography Education
Landscape Photography Education

Medical Intake Form

Medical Intake Form

I know this is very personal information and I respect your privacy, when we are far from emergency services it is imperative that I have this information to keep you as safe as possible. I am a certified Wilderness First Responder, I have been specially trained to know how to respond to emergencies in remote locations. If you do not share this information I may not be able to give you the proper care you need if something were to go wrong in the field.

When you come to the tour/workshop you must bring any required medication, if you list it here and do not have it along, you cannot participate. If you have an EpiPen or asthma inhaler, bring it, I can be held liable if you do not have them, so I will be checking!

Please review the HIPAA Notice

If you have nothing to list here please submit it blank with your name so I know you have reviewed this. Thank you! Now let's have a fun and safe time!

Name *
Please list any medical conditions such as heart disease, diabetes, asthma, etc.
Please list any known allergies to food or medicine
Please list any medications you are taking along with their dosage
Please list any major surgeries or hospitilizations
Anything else I should know?
I understand that David Kingham is not a medical doctor and cannot provide medical advice or care, only provide assistance to proper care if needed.