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Personal Contact Details
1) Name: (First, Middle, Last)
2) Address: (House Number, Street Name, Area, ZIP, City, Region)
3) Home phone:
4) Mobile phone:
5) Work phone:
6) Private fax:
7) E-mail:
8) Alternative email:
Personal Contact Details
1) Full name
2) Gender:
3) Other Names
4) Maiden Name
5) Date of birth:
6) Place of birth:
7) Citizenship:
8) Passport no:
9) National insurance no:
10) Blood group:
11) Significant medical info:
Signed up with
1) Cryonics Provider (Number, Policy Number, Details)
2) Life insurance (Number, Policy Number, Details)
3) Medical insurance (Number, Policy Number, Details)
Contacts
1) Most helpful contact: First Name, Last Name, House Number, Street Name, Area, ZIP, City, Region, Home Phone, Mobile Phone, Work Phone, email, relationship, knows about Cryonics?, comments
2) 2nd. Most helpful contact: as above
3) 3rd. Most helpful contact: as above
4) Next of Kin: as above
5) Most helpful family contact: as above
6) Least helpful family contact: as above
7) Doctor: as above
8) Local Coroner: as above
Important details for emergency
1) 1st local hospital: House Number, Street Name, Area, ZIP, City, Phone, Alternative Phone, comments
2) 2nd local hospital: as above
3) 3rd local hospital: as above
4) 4th local hospital: as above
5) Local Source for ice: as above
6) Local Source for dry ice: as above