Jinair Doctor S Note For Air Travel During Pregnancy
ADVERTISEMENT
1DOCTOR’S NOTE FOR AIR TRAVEL DURING PREGNANCY
This form should be completed by your designated obstetrician in order to confirm your safe air
travel. This checklist will be examined by aviation medical doctor, and he/she may contact your
obstetrician for further information if necessary.
The information collected will be used to evaluate the suitability of your air travel. You have the right
to retain the information, but incorrect information may obstruct decision of suitability.
If your obstetrician is unable to fill out this form, medical certificate or doctor’s note including below
contents is also acceptable.
1. PASSENGER / AIR TRAVEL INFORMATION
NAME
AGE
FLIGHT SCHEDULE
2. DELIVERY EXPERIENCE
□ NONE
□ YES ( ______ times)
PREVIOUS DELIVERY
PRETERM DELIVERY
□ NONE
□ YES
3. CURRENT PREGNANCY INFORMATION
GESTATIONAL AGE (As of now)
WEEKS
DAYS
□ SINGLE
□ MULTIPLE
SINGLE/MULTIPLE PREGNANCY
(Number of fetus : _____ )
EXPECTED DATE OF DELIVERY
DD
/
MM
/
YYYY
PREGNANCY COMPLICATION
□ NONE
□ YES(
)
(Premature rupture of membrane,
placenta previa, preterm labour, etc)
□ Suitable
□ Unsuitable
OPINION ABOUT AIR TRAVEL
□ Doctor’s confirmation before return flight required
(Including return travel within 7 days)
4. ADVICE / COMMENTS
DATE OF COMPLETION:
NAME OF HOSPITAL/MEDICAL INSTITUTION:
LICENSE No:
NAME OF DOCTOR:
(Signature)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical