Name *
Last Name *
Birth date (MM/DD/YYYY) *
Sex MasculinFemenin
Document Type and Number *
Nationality *
Address: Street and number *
City *
Postal Code
Province / State *
Country *
Phone
Cell *
Email *
Name of the trip that you will make
Starting date of the trip *
Meeting point
Arrival Date and Time
Arrival
Flight number
Flight coming from
Airline name
Departure Date and Time
Departure time
Emergency Contact Name
Relationship
Email of contact
Contact phone
Insurance company
Type of insurance
Policy Nº
Blood type
Do you have any of the following conditions?
High blood pressure
Type of high blood pressure controlled with medicinecontrolled without medicinenot controlled
Hypertension medicine
Allergy
Allergy type
Diabetes
Diabetes type
Breathing problems, asthma, etc
Problem type
Heart condition
Condition type
Epilepsy
Seizures
Last seizure
Gastrointestinal problems
Hepatitis
Pregnancy
Pregnancy period
Are you taking any medicine?
Describe medicine
Spine problems
Dilslocations?
Where and when?
Do you wear glasses?
Acute Mountain Sickness
Pulmonary edema in high altitude
Altitude and Date
Cerebral Edema in high altitude
Altidude and Date
Frostbites
Where and what grade?
General health? Very goodGoodRegularBad
Altitude surpassed climbing in mountains
Any other condition that affects your health?
Do you have any food restrictions, are you a vegetarian?
Please explain
Do you need to rent any personal mountain gear?
I declare that the information provided is correct. *
4 + 3 = ? Please prove that you are human by solving the equation *
