Doctor’s Note Template for Travel Cancellation

This template is intended for licensed healthcare providers who need to issue a formal medical statement for a patient unable to travel. It is formatted to meet documentation standards required by airlines, travel insurance companies, or travel agencies and presents key medical information in a clear, professional layout. The template ensures that the no-travel recommendation is backed by a specific diagnosis, treatment details, and a medically justified time frame.

How to Use this Template

The template is designed to be filled out by a physician who has examined the patient and determined that travel is not advisable. The following section breaks down how each part should be completed.

Doctor’s Details

This section contains details about the physician responsible for the recommendation. It includes the doctor’s name, qualifications, license number, and contact information. These entries confirm that the document was issued by a licensed professional and provide a way for the recipient to verify the source if needed.

Date

This is the date the note is issued. It confirms when the recommendation was made and is often reviewed by travel providers or insurers to check if the document was submitted within the required time frame.

Patient Information

Enter the patient’s full legal name and date of birth. These details should match the information used for travel bookings or insurance records. Any mismatch can lead to delays or rejection during verification.

Diagnosis and Treatment Record

Use this section to document each relevant medical evaluation. For every entry, include the date of examination, the diagnosis made, and the treatment prescribed. These entries provide the clinical basis for the travel restriction and confirm that the patient has received formal care. The timeline is important for the recipient to understand the condition and the reasoning behind the recommendation.

Medically Unfit to Travel Period

Enter the specific start and end dates during which travel is not advised. These dates should be based on the medical condition and the expected course of treatment or recovery. Travel providers often refer to this period when assessing eligibility for cancellations or rescheduling, so it should reflect a clear medical judgment.

Reason for Travel Cancellation

Select one or more reasons from the checklist provided in the template. Common options include acute illness, surgical recovery, or pregnancy-related complications. A short explanation should be added next to each selected reason to clarify how the condition interferes with travel. If none of the listed options apply, choose “Other” and specify the reason.

Additional Medical Justification

Use this section to add further context if needed. The physician may describe complications, risks, or recovery requirements that make travel unsuitable during the specified period. This explanation in addition to the brief information provided in the previous section can reduce the chance of follow-up requests from the travel provider or insurer.

Fitness for Future Travel

In this section, the physician can state if the patient is expected to recover by a specific date, requires a follow-up evaluation or is permanently unfit for travel. This clarification will determine if the travel cancellation is temporary or ongoing.

Attachments

Use this section to mention any supporting documents included with the note, such as lab reports, imaging results, or hospital discharge summaries. These attachments are optional but may be requested by the travel provider or insurer to verify the medical recommendation.

Disclaimer

This statement explains that the recommendation is based on your medical assessment at the time of writing. It does not guarantee approval from the travel provider or insurer, as final decisions depend on their specific policies. Including this section is recommended to limit liability and clarify that the note reflects medical opinion, not policy authority. If you want to strongly support the patient’s case, you may remove or reword this section as needed.

Signature and Date

Once all sections are completed, sign and date the document at the bottom. If submitting a printed version, use a handwritten signature. For digital use, a scanned or typed signature may be acceptable depending on your preference or the travel provider’s requirements.