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Alanya Meeting Germany
07400 | Alanya

+90 506 837 8326

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EMERGENCY FORM | SOS CARD

1 | My data

First name*

lastName*

*

masculine

female

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Date of birth*

Day

Month

Year

Telephone number*

E-mail*

2 | Notify people in an emergency

*

family member

hearing

deaf

blind

Contact person

Name first Name*

Telephone number*

address*

E-mail address*

Contact person

Name first Name*

Telephone number*

address*

E-mail address*

Advance directive

Advance directive*

Yes

No

Name first Name*

Telephone number*

3 | FAMILY DOCTOR / HEALTH INSURANCE COMPANY

Name of family doctor*

Practice telephone number*

Name of health insurance company*

Insurance number*

4 | IMPORTANT INFORMATION

Pre-existing conditions*

Blood group including Rhesus factor*

Allergies*

pacemaker*

Yes

No

Implanted defibrillator*

Yes

No

Acute illnesses*

Vaccination certificates*

Organ donor card*

Yes

No

Primary language

Secondary language

Please upload a passport photo

Signature*

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Here you can sign digitally (also with the mouse).

You can also upload a picture of your signature.

I declare that the information I've provided is accurate and complete.

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