Fillable Passenger Medical Certificate Dragonair (Page 2 of 2) in pdf

PASSENGER MEDICAL CLEARANCE FORM (MEDA) – PART 1

- Answer ALL questions

To be completed by

- Put a cross (X) in “YES” or “NO” boxes

PASSENGER

- Use BLOCK LETTERS when completing this form

Surname ____________________________________ First Name _____________________________ Title _________

Airline ____ Flight No ________ Class ____ Date __________ Origin _________ Destination ________ Status _______

* Transfer from one flight to another often requires longer connecting time

Nature of Medical Condition/Incapacitation ____________________________________



Is stretcher needed on board? No

Yes

* All stretchers cases MUST be escorted by medical professionals and additional costs apply

Intended Escort Name _____________________________________________________ Sex ________Age ______

Professional qualification ______________________________________ (if untrained, state “TRAVEL COMPANION”)

Segments (if different from passengers) _____________________________________________________________

* For blind and/or deaf, state if escorted by trained dog





Wheelchair needed? No

Yes

To: boarding gate

aircraft door

seat

inflight





Own Wheelchair?

Yes





Collapsible?

Yes

Power driven? No

Yes

Spillable battery? No

Yes

* Wheelchairs with spillable batteries are "restricted articles" and are permitted on passenger aircraft only under certain conditions

which can be obtained from the airline(s). In addition, certain countries may impose specific restrictions.



Ambulance needed? No

Yes

(Passenger or attending doctor is responsible for making all ambulance arrangements)

Ambulance company contact ____________________________________________________________________

Destination address ______________________________________________ Tel: (

)_________________





Other ground arrangement needed? No

Yes

If Yes, specify below and indicate for each item:

(a) The ARRANGING airline or other organization

(b) At whose EXPENSE, and

Arrangements for drop-off

Details: ______________________________________





Yes

delivery at DEPARTURE airport

_____________________________________________

Arrangements for assistance at

Details:_______________________________________





Yes

CONNECTION POINT

_____________________________________________

Arrangements for pick-up at

Details: ______________________________________



Yes

ARRIVAL airport

_____________________________________________

Other requirements or relevant

Details: ______________________________________





Yes

information

_____________________________________________



Special In-flight arrangements needed? No

Yes

(e.g. special meal, special seating, oxygen or medical

equipment*, assistance with medications, feeding or elimination functions**… etc)

If Yes, DESCRIBE and indicate for each item:

(a) SEGMENT(s) on which required

(b) airline-ARRANGED or arranging third party, and

* Provision of SPECIAL EQUIPMENT such as oxygen etc. always requires completion of PART 2. See “NOTE” at the end of PART 2.

**While our cabin crew will do everything possible to provide assistance to passengers during the flight, please note that we are unable to provide

passengers with any assistance for personal care needs such as feeding, elimination functions including assistance inside the lavatory or other

personal care needs. Additionally, cabin crew are trained only in FIRST AID and are NOT PERMITTED to administer any injection or medication.

Details: __________________________________________________________________________________________

_________________________________________________________________________________________________



Does this passenger hold a “Frequent Travellers Medical Card” (FREMEC) valid for this trip? No

Yes

If Yes, add below FREMEC data to your reservation requests

If No (or if additional data needed by carrying airlines(s)), have attending doctor complete PART 2

FREMEC No. _________________________ Issued by ____________ Valid until _____________

Incapacitation _________________________________ Limitation __________________________________________

PASSENGER’S DECLARATION

I HEREBY AUTHORISE ________________________________________________________________________ (NAME OF NOMINATED DOCTOR)

to provide the airlines with the information required by those airline’s medical departments for the purpose of determining my fitness for carriage by air and in consideration thereof I

hereby relieve that doctor of his/her professional duty of confidentiality in respect of such information, and agree to meet such doctors fees in connection therewith;

I take note that, if accepted for carriage, my journey will be subject to the general conditions of carriage / tariffs of the carrier concerned and that the carrier does not assume any special

liability exceeding those conditions / tariffs. 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 and agents from any liability for such consequences.

I agree to reimburse the carrier upon demand for any special expenditures or costs in connection with my carriage. (where needed to read by/to the passenger, dated and signed by him/her

behalf)

Address:

Date:

Passenger’s Signature:

Revised

2011

Passenger Medical Certificate Dragonair Page 2

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