Federal Aviation Administration Medical Certificate Form

Federal Aviation Administration Medical Certificate Form - Avianca Page 3

Do they require any medication? Which?:

________________________________________________________________________________

If the event supplemental oxygen in flight is required – For the use of an oxygen concentrator

POC: _____ LPM and brand of the equipment

I, Dr. ____________________________________________________ with professional medical

record No .___________________ and identification No. ___________ hereby declare and certify

that this patient is under my care and is fit to safely undertake a flight without requiring any other

medical care during their trip, even if the trip takes longer than expected or were it to finish at

some point other that the planned destination due to operational requirements or for reasons

beyond the control of the airline or if any other unforeseen event occurs during the scheduled

itinerary. I also certify that the aforementioned patient does not suffer from any infectious disease

or any other illness that may be transmitted to other Travelers during the trip.

I also certify that the patient is hemodynamically stable and not in a critical condition, and as such

can travel in commercial aircraft without requiring the service of an air medical ambulance.

I hereby provide my personal data to answer any questions during the analysis and approval by

the company doctors or airport health department, who are those persons responsible for issuing

the final authorization.

Full name of the doctor: ___________________________________________________

Certification issue date: ______day/______month/_______year

Specialty: _________________________________________________________________

Address: ______________________________________________________________________

Landline and mobile telephone including area or country code:

(____) __________________________________(____) _______________________________

Entity where they work: ____________________________________________________________

Signature and seal of the doctor and/or the entity where they work:

_________________________________

FR-OP301-07

Federal Aviation Administration Medical Certificate Form - Avianca Page 3