Medical Information Form - Aer Lingus (Page 2 of 2) in pdf

Please NOTE*

Passenger's must be able to use normal aircraft seat with seatback placed in the UPRIGHT position when so required.

All passengers must be able to take care of their own needs onboard UNASSISTED (including meals, to and from lavatory, etc)

Cabin attendants are NOT authorised to give special assistance to particular passengers, to the detriment of their service to other passengers.

Additionally, they are trained only in first aid and are NOT PERMITTED to administer any injection, or give medication.

Physicians Statement

I, __________________________________, (MD, DO) licensed to practise medicine in the province/state of

______________________________, certify_____________________________________ is a patient under my care. It is my professional

judgment that he/she is physically able to complete an airline flight safely without requiring extraordinary medical assistance, even if the

flight is of greater length than scheduled, terminates at a point other than the expected destination, or involves other irregular operations.

I further certify that the above-mentioned patient does not have a disease or infection that can be transmissible to other persons during the normal

course of the flight.

(Where needed to be read by/to the passenger, dated and signed by him/her, or on his/her behalf).

Physicians prognosis for trip:

Passengers Signature:

Date:

Attending Physicians Signature

Date:

Portable Oxygen Concentrator, C-PAP, Nebulizer, Respirator, Ventilator

Section 2

Medical Equipment

Device Type:

Battery Dry Cell (yes/no):

Device Make:

If Lithium Ion, Watt Hour (Wh)Rating:

Device Model:

Device stamped FAA Approved (yes/no):

Serial No:

Your device has been approved by Aer Lingus and the FAA for travel on the basis that it will not interfere with the safe operation of our aircraft. However, Aer

Lingus is unable to assess the efficacy of a particular medical device when operated in an aircraft cabin environment. We therefore recommend that you

consult the equipment manufacturer and your prescribing physician to confirm that your medical device is suitable for in-flight use. It is the passenger's

responsibility to ensure they have 150% (One Hundred and Fifty) scheduled flight's duration in battery life

Passengers Signature:

Date: