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The information on this form
will only be used by the IFOPE Emergency Response Team in the
event you become incapacitated while in Puerto
Escondido.
Personal
Information
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Bold fields are
required |
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Last
Name |
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First
Name |
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Middle &/or Maiden
Name |
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Name of Spouse/Partner/Significant
Other |
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Street Address (in Puerto
Escondido) |
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Telephone (In Puerto
Escondido) |
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Email |
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Permanant Street
Address |
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Permanent
City/State/Provence/Country/Postal
Code |
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Citizenship |
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Passport
Number |
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Social Security Number/Government ID
Number |
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EMERGENCY CONTACT
PERSONS
Please list up to three persons you wish
to have notified in the event of an emergency, in order of
preference.
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Contact #1
Name |
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Relationship of Contact #1 To
You |
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Telephone of Contact #1 (Country
Code, Area Code, Telephone
Number) |
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Email of Contact
#1 |
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Country of Residence of Contact
#1 |
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Contact #2 Name |
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Relationship of Contact #2 To
You |
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Telephone of Contact #2 (Country Code, Area
Code, Telephone Number) |
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Email of Contact #2 |
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Country of Residence of Contact
#2 |
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Name of Contact #3 |
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Relationship of Contact #3 To
You |
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Telephone of Contact #3 (Country Code, Area
Code, Telephone Number) |
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Email of Contact #3 |
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Country of Residence of Contact
#3 |
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MEDICAL
INFORMATION
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Medical Insurance
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I HAVE medical
insurance coverage that covers me while I am in
México. |
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Name of Insurance Company |
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Medical Insurance Policy
Number |
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Telephone Number of Medical Insurance Company
(Country Code, Area Code, Telephone Number) |
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My policy covers
emergency air evacuation.
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I DO NOT have medical
insurance that covers me while I am in
México. |
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Who Will Be Responsible for Your Medical
Bills? |
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Telephone of Person Responsible for Your Medical
Bills (Country Code, Area Code, Telephone
Number) |
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Blood
Type |
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I am willing to be a
Blood Donor, if needed.
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Date of
Birth |
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Please List All Known
ALLERGIES. |
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Please List All Current MEDICAL
CONDITIONS. |
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Please List All MEDICATIONS That You
Are Currently Taking? |
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Name of Your Physician in Puerto
Escondido? |
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Name of your personal physician NOT in Puerto
Escondido? |
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Telephone number of your physician NOT in Puerto
Escondido (Country Code, Area Code, Telephone
Number)? |
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Name of Your Preferred Sanatorio/Clinic in
Puerto Escondido? |
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Name of Your Preferred Hospital in Oaxaca
City? |
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Name of Your Preferred Hospital in México
City? |
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I have a LIVING WILL
and/or ADVANCED DIRECTIVES. |
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Where is this document
located? |
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In the event of your death while in Puerto
Escondido, what arrangements do you wish? |
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Please review your input,
enter the date and click on the submit button
below.
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Today's Date
(Month) |
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Today's Date
(Day) |
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Today's Date
(Year) |
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