Medical Clearance Form

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How to write a Medical Clearance Form? Download this Medical Clearance Form template that will perfectly suit your needs.

Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Medical Clearance Form template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!

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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