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🇦🇫 Afghanistan (‫افغانستان‬‎) +93
🇦🇱 Albania (Shqipëri) +355
🇩🇿 Algeria (‫الجزائر‬‎) +213
🇦🇸 American Samoa +1684
🇦🇩 Andorra +376
🇦🇴 Angola +244
🇦🇮 Anguilla +1264
🇦🇬 Antigua and Barbuda +1268
🇦🇷 Argentina +54
🇦🇲 Armenia (Հայաստան) +374
🇦🇼 Aruba +297
🇦🇺 Australia +61
🇦🇹 Austria (Österreich) +43
🇦🇿 Azerbaijan (Azərbaycan) +994
🇧🇸 Bahamas +1242
🇧🇭 Bahrain (‫البحرين‬‎) +973
🇧🇩 Bangladesh (বাংলাদেশ) +880
🇧🇧 Barbados +1246
🇧🇾 Belarus (Беларусь) +375
🇧🇪 Belgium (België) +32
🇧🇿 Belize +501
🇧🇯 Benin (Bénin) +229
🇧🇲 Bermuda +1441
🇧🇹 Bhutan (འབྲུག) +975
🇧🇴 Bolivia +591
🇧🇦 Bosnia and Herzegovina (Босна и Херцеговина) +387
🇧🇼 Botswana +267
🇧🇷 Brazil (Brasil) +55
🇮🇴 British Indian Ocean Territory +246
🇻🇬 British Virgin Islands +1284
🇧🇳 Brunei +673
🇧🇬 Bulgaria (България) +359
🇧🇫 Burkina Faso +226
🇧🇮 Burundi (Uburundi) +257
🇰🇭 Cambodia (កម្ពុជា) +855
🇨🇲 Cameroon (Cameroun) +237
🇨🇦 Canada +1
🇨🇻 Cape Verde (Kabu Verdi) +238
🇧🇶 Caribbean Netherlands +599
🇰🇾 Cayman Islands +1345
🇨🇫 Central African Republic (République centrafricaine) +236
🇹🇩 Chad (Tchad) +235
🇨🇱 Chile +56
🇨🇳 China (中国) +86
🇨🇴 Colombia +57
🇰🇲 Comoros (‫جزر القمر‬‎) +269
🇨🇩 Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo) +243
🇨🇬 Congo (Republic) (Congo-Brazzaville) +242
🇨🇰 Cook Islands +682
🇨🇷 Costa Rica +506
🇨🇮 Côte d’Ivoire +225
🇭🇷 Croatia (Hrvatska) +385
🇨🇺 Cuba +53
🇨🇼 Curaçao +599
🇨🇾 Cyprus (Κύπρος) +357
🇨🇿 Czech Republic (Česká republika) +420
🇩🇰 Denmark (Danmark) +45
🇩🇯 Djibouti +253
🇩🇲 Dominica +1767
🇩🇴 Dominican Republic (República Dominicana) +1
🇪🇨 Ecuador +593
🇪🇬 Egypt (‫مصر‬‎) +20
🇸🇻 El Salvador +503
🇬🇶 Equatorial Guinea (Guinea Ecuatorial) +240
🇪🇷 Eritrea +291
🇪🇪 Estonia (Eesti) +372
🇪🇹 Ethiopia +251
🇫🇰 Falkland Islands (Islas Malvinas) +500
🇫🇴 Faroe Islands (Føroyar) +298
🇫🇯 Fiji +679
🇫🇮 Finland (Suomi) +358
🇫🇷 France +33
🇬🇫 French Guiana (Guyane française) +594
🇵🇫 French Polynesia (Polynésie française) +689
🇬🇦 Gabon +241
🇬🇲 Gambia +220
🇬🇪 Georgia (საქართველო) +995
🇩🇪 Germany (Deutschland) +49
🇬🇭 Ghana (Gaana) +233
🇬🇮 Gibraltar +350
🇬🇷 Greece (Ελλάδα) +30
🇬🇱 Greenland (Kalaallit Nunaat) +299
🇬🇩 Grenada +1473
🇬🇵 Guadeloupe +590
🇬🇺 Guam +1671
🇬🇹 Guatemala +502
🇬🇳 Guinea (Guinée) +224
🇬🇼 Guinea-Bissau (Guiné Bissau) +245
🇬🇾 Guyana +592
🇭🇹 Haiti +509
🇭🇳 Honduras +504
🇭🇰 Hong Kong (香港) +852
🇭🇺 Hungary (Magyarország) +36
🇮🇸 Iceland (Ísland) +354
🇮🇳 India (भारत) +91
🇮🇩 Indonesia +62
🇮🇷 Iran (‫ایران‬‎) +98
🇮🇶 Iraq (‫العراق‬‎) +964
🇮🇪 Ireland +353
🇮🇱 Israel (‫ישראל‬‎) +972
🇮🇹 Italy (Italia) +39
🇯🇲 Jamaica +1876
🇯🇵 Japan (日本) +81
🇯🇴 Jordan (‫الأردن‬‎) +962
🇰🇿 Kazakhstan (Казахстан) +7
🇰🇪 Kenya +254
🇰🇮 Kiribati +686
🇽🇰 Kosovo +383
🇰🇼 Kuwait (‫الكويت‬‎) +965
🇰🇬 Kyrgyzstan (Кыргызстан) +996
🇱🇦 Laos (ລາວ) +856
🇱🇻 Latvia (Latvija) +371
🇱🇧 Lebanon (‫لبنان‬‎) +961
🇱🇸 Lesotho +266
🇱🇷 Liberia +231
🇱🇾 Libya (‫ليبيا‬‎) +218
🇱🇮 Liechtenstein +423
🇱🇹 Lithuania (Lietuva) +370
🇱🇺 Luxembourg +352
🇲🇴 Macau (澳門) +853
🇲🇰 Macedonia (FYROM) (Македонија) +389
🇲🇬 Madagascar (Madagasikara) +261
🇲🇼 Malawi +265
🇲🇾 Malaysia +60
🇲🇻 Maldives +960
🇲🇱 Mali +223
🇲🇹 Malta +356
🇲🇭 Marshall Islands +692
🇲🇶 Martinique +596
🇲🇷 Mauritania (‫موريتانيا‬‎) +222
🇲🇺 Mauritius (Moris) +230
🇲🇽 Mexico (México) +52
🇫🇲 Micronesia +691
🇲🇩 Moldova (Republica Moldova) +373
🇲🇨 Monaco +377
🇲🇳 Mongolia (Монгол) +976
🇲🇪 Montenegro (Crna Gora) +382
🇲🇸 Montserrat +1664
🇲🇦 Morocco (‫المغرب‬‎) +212
🇲🇿 Mozambique (Moçambique) +258
🇲🇲 Myanmar (Burma) (မြန်မာ) +95
🇳🇦 Namibia (Namibië) +264
🇳🇷 Nauru +674
🇳🇵 Nepal (नेपाल) +977
🇳🇱 Netherlands (Nederland) +31
🇳🇨 New Caledonia (Nouvelle-Calédonie) +687
🇳🇿 New Zealand +64
🇳🇮 Nicaragua +505
🇳🇪 Niger (Nijar) +227
🇳🇬 Nigeria +234
🇳🇺 Niue +683
🇳🇫 Norfolk Island +672
🇰🇵 North Korea (조선 민주주의 인민 공화국) +850
🇲🇵 Northern Mariana Islands +1670
🇳🇴 Norway (Norge) +47
🇴🇲 Oman (‫عُمان‬‎) +968
🇵🇰 Pakistan (‫پاکستان‬‎) +92
🇵🇼 Palau +680
🇵🇸 Palestine (‫فلسطين‬‎) +970
🇵🇦 Panama (Panamá) +507
🇵🇬 Papua New Guinea +675
🇵🇾 Paraguay +595
🇵🇪 Peru (Perú) +51
🇵🇭 Philippines +63
🇵🇱 Poland (Polska) +48
🇵🇹 Portugal +351
🇵🇷 Puerto Rico +1
🇶🇦 Qatar (‫قطر‬‎) +974
🇷🇪 Réunion (La Réunion) +262
🇷🇴 Romania (România) +40
🇷🇺 Russia (Россия) +7
🇷🇼 Rwanda +250
🇧🇱 Saint Barthélemy (Saint-Barthélemy) +590
🇸🇭 Saint Helena +290
🇰🇳 Saint Kitts and Nevis +1869
🇱🇨 Saint Lucia +1758
🇲🇫 Saint Martin (Saint-Martin (partie française)) +590
🇵🇲 Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon) +508
🇻🇨 Saint Vincent and the Grenadines +1784
🇼🇸 Samoa +685
🇸🇲 San Marino +378
🇸🇹 São Tomé and Príncipe (São Tomé e Príncipe) +239
🇸🇦 Saudi Arabia (‫المملكة العربية السعودية‬‎) +966
🇸🇳 Senegal (Sénégal) +221
🇷🇸 Serbia (Србија) +381
🇸🇨 Seychelles +248
🇸🇱 Sierra Leone +232
🇸🇬 Singapore +65
🇸🇽 Sint Maarten +1721
🇸🇰 Slovakia (Slovensko) +421
🇸🇮 Slovenia (Slovenija) +386
🇸🇧 Solomon Islands +677
🇸🇴 Somalia (Soomaaliya) +252
🇿🇦 South Africa +27
🇰🇷 South Korea (대한민국) +82
🇸🇸 South Sudan (‫جنوب السودان‬‎) +211
🇪🇸 Spain (España) +34
🇱🇰 Sri Lanka (ශ්‍රී ලංකාව) +94
🇸🇩 Sudan (‫السودان‬‎) +249
🇸🇷 Suriname +597
🇸🇿 Swaziland +268
🇸🇪 Sweden (Sverige) +46
🇨🇭 Switzerland (Schweiz) +41
🇸🇾 Syria (‫سوريا‬‎) +963
🇹🇼 Taiwan (台灣) +886
🇹🇯 Tajikistan +992
🇹🇿 Tanzania +255
🇹🇭 Thailand (ไทย) +66
🇹🇱 Timor-Leste +670
🇹🇬 Togo +228
🇹🇰 Tokelau +690
🇹🇴 Tonga +676
🇹🇹 Trinidad and Tobago +1868
🇹🇳 Tunisia (‫تونس‬‎) +216
🇹🇷 Turkey (Türkiye) +90
🇹🇲 Turkmenistan +993
🇹🇨 Turks and Caicos Islands +1649
🇹🇻 Tuvalu +688
🇻🇮 U.S. Virgin Islands +1340
🇺🇬 Uganda +256
🇺🇦 Ukraine (Україна) +380
🇦🇪 United Arab Emirates (‫الإمارات العربية المتحدة‬‎) +971
🇬🇧 United Kingdom +44
🇺🇸 United States +1
🇺🇾 Uruguay +598
🇺🇿 Uzbekistan (Oʻzbekiston) +998
🇻🇺 Vanuatu +678
🇻🇦 Vatican City (Città del Vaticano) +39
🇻🇪 Venezuela +58
🇻🇳 Vietnam (Việt Nam) +84
🇼🇫 Wallis and Futuna +681
🇾🇪 Yemen (‫اليمن‬‎) +967
🇿🇲 Zambia +260
🇿🇼 Zimbabwe +263

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Height

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4'
4'1
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4'5
4'6
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4'8
4'9
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4'11
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7
7'1
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7'7
7'8

Weight

Gender*

Male
Female

Marital status

Single
Married
Divorced
Widowed

Tobacco Use

Current or Previous Medical Conditions

(Last 5 Years)

Current Insurance Carrier

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Medicare Number

Medicare Part A- Effective Date

Medicare Part B- Effective Date

Preferred Pharmacy

Medications- (Including dosage and how many times a day it is taken)

Preferred Doctor's Names

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Health Insurance

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Medicare Supplements

Medicare Advantage Plans

Prescription Drug Plans

Long Term Care

Disability

Critical Illness

Hospital Indemnity Plans

Dental, Vision, Hearing

Employee Benefits

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