Medical Information Form - Aer Lingus
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1
2Medical Information Form
If travelling from IRL/UK or Europe, fax completed form to +353 1 886 6868 or email to .
If travelling from USA, email completed form to or fax to 1-516-622-4287.
Medical Information and Physicians Statement
A
PASSENGER
NAME
Home:
PASSENGER
B
Mobile:
CONTACT
NUMBER
Work:
Date of birth
Male
/
Female
C
D
SEX
Transfer from one flight to another often requires
Date
Flight No.
From
To
PROPOSED ITINERARY
LONGER connecting time.
Aer Lingus Confirmation Number (six (6) characters)
E
Departing Flight
Returning Flight
ATTENDING PHYSICIAN
Name
F
Email
Contact Phone
NATURE OF CONDITION, ILLNESS,
G
DATE OF DIAGNOSIS
OR DISABILITY
Does the passenger require
YES
Please Select the rate of flow
2 Litres
YES
Continuous
Supplementary oxygen
2 Litres or 4 Litres per Min
Flow?
during the flight?
NO
NO
4 Litres
H
Intended Escort (Name ,
professional qualification). If
untrained state: TRAVEL
Companion
Collapsible?
*Aer Lingus does not
Own
Non Spillable Battery?
Does the passenger require to
Power Driven?
allow the carriage of
be lifted onto the aircraft?
Wheelchair
I
Spillable Batteries
Yes
No
Yes
Yes
Yes
No
No
Will the passenger be arriving or collected in
an ambulance for departure or upon arrival?
Yes
If so, please specify ambulance contact and
destination address
K
Can the patient use normal aircraft seat with seat back placed in
No
Yes
L
the UPRIGHT position when so required?
Can patient take care of his own needs
No
on board
UNASSISTED * (including
meals, visit to toliet etc.)
M
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Parent category: Medical