cphil phone +45 3232 1666, +45 32 32 68 98 fax +45 32 32 64 72 e-mail [email protected] confidential ============ for
CPHIL
Phone +45 3232 1666, +45 32 32 68 98
Fax +45 32 32 64 72
E-mail [email protected]
Confidential
============
For official only
Medical information form - medif
To be completed
by
Attending Physician
This form is intended to provide Confidential information, to enable
the airlines’ Medical
Departments to assess the fitness of the passenger to travel. If the
passenger is acceptable, this
information will permit the issuance of the necessary directives
designed to provide for the passenger’s welfare and comfort.
The Physician Attending the incapacitated passenger is requested to
Answer All Questions (Enter
a cross «x» in the appropriate «yes» or «no» boxes, and/or give
precise concise answers).
Use Block Letters or Typewriter when completing this form. Fill in
this form in English, German,
French or Italian.
Please return the completed form to
Address of issuing SAS office
Airlines’
Ref Code
Meda01
Patient’s name,
initial(s), sex, age
Meda02
Attending Physician
Name & Address
Telephone Contact
Business
Home
Medical Data
Diagnosis in details
(including vital signs)
Meda03
Day/month/Year of first symptoms
Date of operation
Date of diagnosis
Meda04
Prognosis for the flight(s)
Meda05
Contagious And communicable disease?
No
Yes
Specify
Meda06
Would the physical and/or mental condition
of the patient be likely to cause distress or
discomfort to other passengers?
No
Yes
Specify
Meda07
Can patient use normal aircraft seat
with seatback placed in the Upright
position when so requiered?
Yes
No
Meda08
Can patient take care of his own needs
on board Unassisted *(including meals,
visit to toilet, etc)?
Yes
No
If not, type of help needed
Meda09
If to be Escorted, is the arrangement
satisfactory to you?
Yes
No
If not, type of escort proposed by You
Meda10
Does patient need Oxygen **
equipment in flight? (If yes,
state rate of flow)
No
Yes
Litres per Minute
Continuous?
No
Yes
Meda11
Does patient need any
Medication *, other than
self-administrered, and/or
the use of special apparatus
such as respirator,
incubator, etc **?
(a) on the Ground while at the airport(s)
No
Yes
Specify
Meda12
(b) on board of the Aircraft
No
Yes
Specify
Does patient need
Hospitalisation? (If yes,
indicate arrangements
made or, if none were
made, indicate
«No Action Taken»)
(a) during long layover or nightstop at Connecting Points en route
Meda13
No
Yes
Action
Meda14
(b) upon arrival at Destination
No
Yes
Action
Other remarks or
information in the
interest of your
patient’s smooth
and comfortable
transportation
Meda15
None
Specify if any **
Meda16
Other arrangements
made by the
attending physician
Note(*) Cabin attendants are Not authorized to give special
assistance to (e g lifting)
particular passengers, to the detriment of their service to other
passengers.
-Additionally, they are trained only in First Aid and are Not
Premitted to
administer any injection, or to give medication.
Important Fees, if any, relevant to the provision to the above
information and for carrier – provided special equip-
ment (**) are to be paid by the passenger concerned.
Date
Place
Attending Physician’s Signature
Passenger’s declaration
«I hereby authorize
(name of nominated physician)
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 thereof.
I hereby relieve that physician of his/her professional duty of
confidentiality in respect of such
information, and agree to meet such physician’s 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 agree to reimburse the carrier upon demand for any special
expenditures or costs in
connection with my carriage».
(Where needed, to be read by/to the passenger, dated and signed by
him/her, or on
his/her behalf).
Place
Date
Passenger’s Signature