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Please answer the questions below and click the submit button to e-mail your completed questionnaire to us. We will contact you with a quote for your customized medical kit.

Ship Captain / Owner

Captain's Name:
e-mail:
Company/Owner:
Street Address:
City, State, Zip: ,
Phone (day / evening):
FAX:

Vessel Specifications

Size:
Homeport:
Type:
Primary Use:
Engine Type:
Ship Phone:

Additional Information

Ship Point of Contact:
Area of Operation:
Months at Sea: , to
What is the typical water/air temperature? Water: Air:
Number of Crew:   % Male:  % Female: Median Age:
Number of Passengers:  % Male:  % Female: Median Age:
Do any crew members have any chronic illnesses?
If so, please detail.
Are any crew members taking any prescription medications?
If so, please detail.
Describe any medical problems experienced on board in the last 12 months.
Please provide a list of your current medical assets.
What are the average sea and weather conditions in which you will be operating?
Who is your ship's physician? (Name, address, telephone)
Medical Space Allocation?
(i.e. Cabinet/Room)
Level of training of assigned medical personnel:
Please select all that apply.
M.D. EMT
R.N. Corpsman
R.Ph. CPR/First Aid
When will you be needing your kit?*
Please send us any additional comments and questions.
*Emergency Medical Kits featuring prescription medication
require 10 working days for preparation.

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