Medical Information Form

First Name

Last Name

Age

Phone Number

Emergency Contact Information

First Name

Last Name

Emergency Contact Phone Number

Relevant Medical Information

Do you have any allergies to medications?YesNo

Please list your medication allergies.

Do you have any serious environmental allergies?YesNoE.g., Bee allergy requiring EpiPen administration

Please list environmental allergies.

Do you have any chronic medical conditions which may impact your first aid care?YesNo

Please list your chronic medical conditions.

Do you have any medication that requires special storage, such as refrigeration?YesNo

Do you have any medications which should remain on your person at all times?YesNoE.g. Inhaler, EpiPen

Dietary Restrictions

Do you have any food allergies?YesNoPlease note that Xadune provides food in the Tavern and will do their best to work with all food allergies.

Please list your food allergies.

Do you have any dietary restrictions outside of allergies?YesNo

Please list your dietary restrictions.

Send Message

Xadune does not share your medical information with outside or third-party sources. You may view our Privacy Policy here: https://xadune.com/privacy-policy/