Country of origin | {Country of Origin:65} |
Nationality | {Nationality:90} |
Date of birth | {Date of Birth:118} |
Trip Start | {Trip Start Date:9} |
End of Trip | {Trip End Date:114} |
Trip Duration | {Number of days of the trip: 117} days |
Sex | {Sex:95} |
Total Price | {Amount (Price):125.2} euros |
Name | {Name (Name):76.3} |
Last name | {Surnames (Surnames):112.6} |
Passport number | {Passport No.:77} |
Email | {Email:5} |
Phone | {Phone:12} |
Card Shipping Address | {Address in Spain (for sending medical card) (Street Address):94.1} - {Address in Spain (for sending medical card) (ZIP / Postal Code):94.5}, {Address in Spain (for sending medical card) ) (City):94.3} {Address in Spain (for sending medical card) (State / Province):94.4} |
Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment? | {Do you suffer or have you suffered from any illness or have you suffered an accident in the last five years that required medical treatment?:105}. {Detail if yes:99} |
Do you plan to be hospitalized and/or undergo surgery? | {Do you plan to be hospitalized and/or undergo surgery?:106}. {Detail if yes:107} |
Are you currently under medical treatment? | {Are you currently under medical treatment?:108}. {Detail if yes:109} |
Do you have any symptoms or pain, undiagnosed and manifested continuously or repeatedly? | {Do you have any symptoms or pain, undiagnosed and manifested continuously or repeatedly?:110}. {Detail if yes:111} |