Medical Clearance Form
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How to create a Medical Clearance Form? Download this Medical Clearance Form template that will perfectly suit your needs.
This Medical Clearance Form is intended to provide CONFIDENTIAL information to enable the airline’s MEDICAL Department to assess the fitness of the passenger to travel. If the passenger is acceptable for air travel, this information will permit the issuance of the necessary directives designed to provide for the passenger’s welfare and comfort. The PHYSICIAN ATTENDING of the passenger is requested to ANSWER ALL QUESTIONS. Enter a Check “¨ in the appropriate boxes, and / or give precise concise answers
Size： Width Depth Height Period of usage Continuous 【□ Centimeter / □ Inches】 □ On Ground □ During Flight □ No □ Yes □ No □ Yes □ No □ Yes Can passenger use the medical device(s) unassisted？ Does passenger need any MEDICATION , other than self-administered ？ MEDA 12 Specify if YES： □ No □ Yes Can it be administered by the escort？ MEDA 13 MEDA 14 Does passenger need HOSPITALISATION during transit/transfer at CONNECTING POINTS If yes, indicate arrangements made： Does passenger need HOSPITALISATION upon ARRIVAL？ GA：weeks + day(s) □ No □ Yes □ No □ Yes If yes, indicate arrangements made： □ No □ Yes Is passenger PREGNANT？ MEDA 15 □ No □ Yes EDD：// Gestation：□ Single □ Multiple Other remarks, information and arrangements made： MEDA 16 Date： Place： Attending Physician s Signature： Date： Place： Passenger’s Signature： 1、 Cabin crew are NOT authorized to give special assistance to passengers such as personal care and lifting..
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