Physician Consent Form For An Individual Who Needs To Use A Portable Oxygen Concentrator (Poc) During An Allegiant Air Flight printable pdf download

Physician Consent Form For An Individual Who Needs To Use A Portable Oxygen Concentrator (Poc) During An Allegiant Air Flight

Physician Consent Form for an Individual Who Needs to Use a

Portable Oxygen Concentrator (POC) During an Allegiant Air Flight

(Must be completed in full by the Customer’s Physician and printed on Physician’s letterhead)

Physician’s Name: ________________________________________

Place of Business: ________________________________________

Address:

________________________________________

Telephone:

________________________________________

Fax:

________________________________________

1. Please note that, in accordance with Special Federal Aviation Regulation (SFAR) No. 106, 14

CFR Part 121, only the AirSep Freestyle, AirSep Lifestyle, DeVilbiss Healthcare’s iGo, Oxus, Inc.

RS-00400, also known as: EVO Central Air (Delphi RS-00400), Inogen One, Inogen One G2,

Inova Labs LifeChoice – also known as: International Biophysics Corporation’s LifeChoice,

Invacare XPO2, Invacare Solo2, Oxlife’s Independence Oxygen Concentrator, Respironics Evergo

and Sequal Eclipse, AirSep Focus, AirSep Freestyle 5, Inogen One G3, Inova Labs LifeChoice

Activox, Respironics Simply Go, Precision Medical EasyPulse, SeQual SAROS, SeQual eQuinox

Oxygen System model 4000, Oxywell Oxygen System model 4000, and VBOX, Inc. Trooper models

are approved for use during flight.

Compressed or liquid medical oxygen may not be used or transported on any Allegiant Air

flight.

The following information relates to _____________________________, who is a patient in my care.

He/She:

(

)

Passenger/Patient Name

• has the physical and cognitive ability to see, hear and understand the POCs aural and visual

cautions and warnings and is able, without assistance, to take the appropriate action in response

to those cautions and warnings.

Yes _____ No_____ . If the answer no, the Passenger/Patient must travel with a companion

who is able to perform these functions. _____ (initial)

• will require the use of the device during (check all that apply)

taxi_____, take-off_____, in air_____, and/or landing_____.

• will be using a device with a maximum oxygen flow rate of _______________, corresponding to

the pressure of the aircraft under normal operating conditions.

____________________________

___________________________

(Physician’s signature)

(Date*)

* Form must be dated within one (1) year of travel date.

NOT VALID UNLESS PRINTED ON PHYSICIAN’S LETTERHEAD

Revised 2/2014

Physician Consent Form For An Individual Who Needs To Use A Portable Oxygen Concentrator (Poc) During An Allegiant Air Flight