Travel Preparedness Form

Travel Preparedness

Print this form for your trip. Also leave a copy at home with a friend or relative.

Personal Information
Full Name	eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee
Home Address
Home Phone Number
Fire Station (Medicine storage option during power outage.)	Phone Number: Address:
Pharmacy (Medicine storage option during power outage.)	Phone Number: Address:
Hospital (Medicine storage option during power outage.)	Phone Number: Address:

Emergency and Medical Information
In Case of Emergency, Contact Full Name	eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee
Emergency Contact’s Phone
Doctor’s Name
Doctor’s Phone
Doctor’s Address
Doctor’s Name
Doctor’s Name
Doctor’s Phone
Doctor’s Address
Medical Insurance Carrier and Number
Blood Type
Known Medical Conditions	Hypophosphatasia (HPP) a rare genetic disorder characterized by impaired mineralization of bones and teeth.
HPP Care Instructions	Handle with care. Defective mineralization results in bones that are soft and prone to fracture and deformity.
Current medications and what they are for
Medication Instructions
Known Allergies

Patient Assistance Information
ONESOURCE PATIENT SUPPORT PROGRAM – PERSONALIZED TRAVEL SUPPORT	1.888.765.4747 eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee
PANTHERX RARE PHARMACY TM	855.726.8479 • (412.246.9858)
Primary Pharmacy Home
Primary Pharmacy Address

Airline Information	Flight #1	Flight #2	Flight #3	Flight #4
Date of Flight
Airline
Airline Phone Number
Flight Number
Departure City
Departure Time
Destination City
Arrival Time

Hotel Information
Date of Check-In	Hotel ———————————— .,	City, State, Country	Reservation Confirmation Number	Hotel Phone Number

Travel Tips: Key Considerations

Have a list of all medications, dosage, and frequency. Include the name and number of the prescribing doctor. Have an emergency health information card with the patient’s name and how to handle a medical emergency, with a list of contacts.

When traveling, consider options for backup refrigeration in case of power failure.

A car refrigerator can be used to keep medicine cool while traveling. If flying, keep STRENSIQ® in the cabin; do not check it with luggage. Insulated travel cases are useful to keep medication protected and cold.

Consider access to alternative power options, such as a generator. Monitor temperature with a thermometer.
Note: WiFi thermometers may be impacted by power outages.

Create a contingency plan for medication refrigeration and identify a person to transport it to an alternative storage location.

Identify a fire station, pharmacy, hospital, or other storage options and call in advance to confirm the ability to store refrigerated medication.