| The information on this form will be be used by the
IFOPE Emergency Response Team in the event you become
incapacitated while in Puerto Escondido. All responses
are voluntary: leave blank any field you do not wish to
disclose. |
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Personal
Information
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Last Name: |
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First Name |
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Middle and/or Maiden Name: |
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Street Address in Puerto Escondido
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Telephone Number in Puerto
Escondido: |
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Email Address: |
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Permanent Street Address: |
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Permanent
City/State/Province/Country: |
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Citizenship: |
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Passport Number: |
Emergency Contact
Persons
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Contact #1 Name: |
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Relationship to You: |
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Telephone Number (Country Code, Area Code,
Telephone Number):
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Email Address: |
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Country of Residence: |
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Contact #2 Name: |
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Relationship to You: |
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Telephone Number (Country Code, Area Code,
Telephone Number):
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Email Address: |
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Country of Residence: |
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Contact #3 Name: |
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Relationship to You: |
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Telephone Number (Country Code, Area Code,
Telephone Number):
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Email Address: |
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Country of Residence: |
Medical Information
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I HAVE medical insurance
that covers me while I am in México.
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Name of Insurance Company:
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Insurance Policy Number: |
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Telephone Number of Insurance Company (Country
Code, Area Code, Telephone Number):
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My policy covers
emergency air evacuation.
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If you do NOT have medical insurance that covers
you in México, who will be responsible for your medical bills
here?
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Telephone Number of This Person (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 (MM/DD/YYYY) |
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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 personal PHYSICIAN in Puerto
Escondido: |
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Telephone Number of this physician:
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Name of your personal PHYSICIAN NOT in Puerto
Escondido:
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Telephone Number of this physician (Country
Code, Area Code, Telephone Number):
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Preferred Sanatorio/Clinic in Puerto
Econdido: |
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What is your preferred Hospital in OAXACA
CITY?
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What is you 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 enter TODAY´S DATE
(MM/DD/YYYY): |
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