Help yourself by printing out and completing this form.
Always keep a copy with you.
If ever you are ill or in an accident it will be of great benefit
both to you and the hospital
Surname
Apellido
Forenames
Nombres
Resident/Tourist
Residente o turista
Nationality
Nacionalidad
Home Address
Domicilio habitual
Address in Spain
(if different)
Direccion en España
Telephone
Telefono
Date of Birth
Fecha de nacimiento
Name, address & telephone number of person to be contacted if admitted to hospital
Nombre, direccion y n° de telefono de la persona a advertir en caso de ser in resado en el hospital
Spanish Social Security Number
Numero de Seguridad Social Española
NIE (Residencia) No
Numero de NIE/DNI
Passport Number
Numero de pasaporte
Medical insurance company, policy number & telephone number
Seguro medico, numero de poliza y numero de telefono
I have form E111/E121
Tengo E111/E121
Long term illnesses and year first suffered
Enfermedades cronicas y ano de comienzo
Operations and year performed
Operaciones y anos de las mismas
Present medication
Medicamento actual
Allergies to any drugs
Medicamentos no tolerados
Blood Group
Grupo sanguineo