Vessel Name *
Max # of people onboard the vessel? (Do not include Guests) *
Where does this vessel land? Please include the address. *
What is the primary type of vessel? * Scallop trawler Clam trawler Lobster boat Shrimp Trawler Scientific/research Pleasure Craft (Sailing or motor) Passenger Ferry Cruise Ship Seismic Vessel Other
Are Telemedicine services required for this vessel? * Yes No
Vessel Primary Phone number (Normally the main Satellite Phone) *
Vessel Backup Phone number (Can be another Satellite phone) (OPTIONAL)
Vessel Mobile Phone number (Can be another mobile phone) (OPTIONAL)
Do you have a photo of the vessel that you can provide? * Yes No
Company / Organization Name *
Job Title of company representative *
Email of Company Representative *
Phone of Company Representative *
Job Title of Backup company representative
Email of Backup company Representative
Phone of Backup company representative
Do you have a list of the crew/employees that will be onboard this vessel? * Yes No
Do you have a Medical Kit on-site at the vessel? * Yes No
Email of Caller #1 *
Role/Job of Caller #1 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *
Medical Role of Caller #1 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *
Is there a 2nd caller that you'd like to add? * Yes No
Email of Caller #2 *
Role/Job of Caller #2 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *
Medical Role of Caller #2 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *
Is there a 3rd caller you'd like to add? * Yes No
Email of Caller #3 *
Role/Job of Caller #3 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *
Medical Role of Caller #3 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *
Is there a 4th caller you'd like to add? * Yes No
Email of Caller #4 *
Role/Job of Caller #4 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *
Medical Role of Caller #4 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *
Are there any special notes that you'd like to tell us? (Optional)