Airways Passenger Medical Form
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1
2MEDICAL INFORMATION
PART 1
Doctors/Office use only
TO BE COMPLETED BY THE PASSENGER (PLEASE PRINT IN BLOCK CAPITAL LETTERS)
1.
Family name
Given name
Title
Age
OFFICE USE ONLY
Address
Telephone contact No.
2.
Ref. No.
From
To
3.
Proposed Itinerary: Flt. No.
Date
Information Complete
Whats is the nature and duration of your illness/injury
4.
Clearance not required
Type of assistance required
Ground
If you are being escorted, please provide details of your escort:
5.
Wheel chair
Stretcher
Name
Title
Age
Qualifications
Escort
6.
Do you require a wheelchair?
for long distances
Oxygen required
to aircraft door
2L/m
to aircraft seat
4L/m
continuous
7.
Would you prefer
Aisle seat
intermittent
seat near toilet
No. of cylinders need
8.
Do you need an ambulance
Yes
No
Medical equipment required
All ambulances have to be arranged by the treating doctor/hospital/evacuation company.
Clearance CANNOT be given until bookings are confirmed.
Equipment approved
9.
Have ambulance transfers been confirmed in
Departure port
Transit port
Approved for uplift
Arrival port
Dr’s sig.
Date
Do you have a life-threatening allergy to any food types?
10.
Time
Please specify
Approved for uplift
Reeservation
11.
Do you need to use electrical equipment powered by the aircraft supplies?
Yes
No
Date
Please specify
Time
PASSENGER’S DECLARATION
I HEREBY AUTHORISE
(Name of treating doctor)
to provide the airlines with the information required by those airlines medical departments for the purpose of
determining my fitness for carriage by air and in consideration therefore I hereby relieve the physician of his/her
professional duty of confidentiality in respect of such information, and agree to meet such physician’s fee in
connection therewith.
I am prepared at my own risk to bear any consequences which carriage by air may have for my state of health
and I release the carrier, its employees, servants agents and doctors from any such liability for such consequence.
PASSENGER’S
SIGNATURE
Date
Place
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