MEDICAL CERTIFICATE OF FITNESS FOR AIR TRAVEL
1. Name of Passenger (Print): _________________________
2. Age: _________
3. Address & Phone number: ___________________________
______________________________________________________
4. Diagnosis of condition: __________________________
5. Whether infectious or non infectious? _____________
6. Nature of treatment: _______________________________
7. Can passenger walk unaided? ________________________
8. Can passenger travel in sitting position for the duration of the flight?__________
9. Does passenger require supplemental oxygen?_________
10. Extra requirements needed for safety and comfort of passenger?_____________________________________________
_______________________________________________________
Medical Authorization
It is my professional opinion that the above named individual is medically fit to travel by air in a non-pressurized aircraft from _____________ to ____________.
Health Care Provider Name: (Print)____________________
Address: _____________________________________________
Tel/Fax: _____________________________________________
Remarks of Health Care Provider:
_______________________________________________________
_______________________________________________________
Signature: ____________________________________________
Date: _________________
Passenger Authorization
I authorize my health care provider to provide the above information on my behalf.
SIGNATURE OF PASSENGER:________________________________
Date: ______________