This form is to assist your Consultant in Quoting. Furhter information and assessments may be required directly with the Insurance Provider

e.g. insulin for diabetes, aspirin for strokes, Paracetamol for back pain , having regular check-ups? or under investigation, waiting on a diagnosis or surgery?
Kidneys, Liver / Cancer (even if in remission) / Joint, back or spine / Brain e.g. Dementia, Epilepsy, head injury, Tumours / Any heart-related condition e.g. Angina, bypass surgery, heart attack, irregular heart rhythms, stents / Strokes e.g. clots, Deep Vein Thrombosis, mini strokes, Pulmonary Embolism / Respiratory system e.g. Chronic Bronchitis, COPD, Emphysema
Have there been complications with this or a previous pregnancy? / Is it a multiple pregnancy e.g.twins or triplets ? / Was the conception medically assisted? e.g. using assisted fertility treatment including hormone therapies or IVF ?(Pregnancy cover is limited to unexpected complications up to the 24th week. Childbirth or care of a newborn is not covered)


Your Personal & Medical Information is confidential between you and your Consultant. We may need to disclose this information with the insuerer and/or Travel Provider with your permisson.

We welcome you to speak with us for more information
on any of our services or special offers.

East Ivanhoe Travel acknowledges and pays respect to the past, present and future Traditional Custodians and Elders of this nation and the continuation of cultural, spiritual and educational practices of Aboriginal and Torres Strait Islander peoples.