Federal Aviation Administration Medical Certificate Form

Federal Aviation Administration Medical Certificate Form - Avianca Page 2

Confirmation/reservation number: Flight number / date

____________________________________________________

Traveler's phone numbers including area or country code:

(____) __________________________________(____) _____________________________

Phone numbers of a relative at the place of origin including the country or area code:

(____) __________________________________(____) _____________________________

MEDICAL INFORMATION

This information must be filled out only by the attending physician of the Traveler in the fields that

apply.

Age of the Traveler: __________

Start date of the medical condition in question: ______ day / ______ month / _______ year

Diagnosis:

1._____________________________________________________________________________

2._____________________________________________________________________________

3._____________________________________________________________________________

Medical treatments:

1._____________________________________________________________________________

2._____________________________________________________________________________

3._____________________________________________________________________________

Surgery(ies) and their date(s):

1._____________________________________________________________________________

2._____________________________________________________________________________

3._____________________________________________________________________________

Current condition of the patient: their state of consciousness, ability to walk unaided, etc.

________________________________________________________________________________

Federal Aviation Administration Medical Certificate Form - Avianca Page 2