ADVENTURES TO THE EDGE, LTD.
JEAN PAVILLARD MOUNTAIN GUIDE
Po Box 91 Crested Butte, CO 81224
Ph: + 1-970 209 3980
Fax: + 1- 509 471 8412
email: jean@jpmountainguide.com
www.swissmountainguide.com
HEALTH PASSPORT AND INFORMATION. (2009)
(3 pages)
Last Name:
First Name:
Date and place of birth:
Address:
City:
Zip code:
Country:
Phone:
Fax:
E-mail:
Passport #:
Date and place of issue:
IN CASE OF NEED:
Who to contact: #1:
Name:
Address:
Phone:
Fax:
e-mail:
In case of Needs:
Who to contact: #2:
Name:
Address:
Phone:
Fax:
E-mail:
______________________________________________________
FAMILY DOCTOR:
Name:
Address:
Phone:
Fax:
E-mail:
______________________________________________________
INSURANCE:
#1 / Name and address:
Policy #:
Phone:
Fax:
E-mail:
Insurance #2 /
Name and address:
Policy #:
Phone:
Fax:
E-mail:
INTERNATIONAL ASSISTANCE:
Name and address:
Phone:
Fax: E-mail:
PERSONAL INFORMATION:
Blood group / Rhesus factor:
Known allergies or incompatibilities:
Current illnesses:
Previous important medical problems:
Therapies under way:
Emergency medicine for known problems:
Wearing contact lenses:
_______________________________________________________
SUPPLEMENTARY REMARKS:
( about you and about the people we may contact. Best time, home or office who is more likely to
answer the phone, how to relay messages, etc. Dietary needs.
Allergies, medical history, previous injuries.)
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