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MEDIF
Standard medical information form for air travel

Page 1CONSENT FOR FINNAIR TO HANDLE SENSITIVE PERSONAL DATA
By submitting this form, you give us your consent to process your medical data to handle and complete your service request. The consent also applies to our partners ifnecessary. Find out more about our Privacy Policy: https://www.finnair.com/privacy-policy/
Name

Date and place

Signature

The Sales office, agent or passenger should complete this form.
Please answer all of the questions, marking an ‘x’ in the ‘Yes’ or ‘No’ boxes and using block letters or typing when completing the form.
1. Passenger’s first nameLast nameDate of birthGender

2. Proposed itinerary: date(s), flight number(s), from-to
3. Diagnosis or other reason for special arrangements
4. Is the passenger able to walk 50 meters or climb 10-12 steps without difficulties?
Yes
No, specify
5. Is a wheelchair needed?

Weight and measurements of the wheelchairNo
Yes, WCHR (R = Ramp)
The passenger is able to go up/ come down steps and can enter and exit the aircraftby himself/herself.
WCHS (S = Steps)
The passenger is not able to go up / come down steps, but can get on the aircraft seatby himself/herself (needs a wheelchair to get from the terminal to the plane, and is
carried on and off the plane).

Passenger’s own wheelchair
Foldable wheelchair

Motorized wheelchair

Spillable batteries

Non-spillable batteries

Permission for transport of a motorized wheelchair must always
be obtained from the airline in advance.

WCHC (C = Cabin Seat)
The passenger is completely incapable of movement, he/she must be carried to the seaton the plane, and off again.
6. Is an ambulance needed?
NoYes (If yes, specify name and telephone number of ambulance company and name of hospital at destination)
7. Are other ground arrangements needed? Note! Finnair does not provide any ground arrangements.
No

Yes

If yes, specify below contact information of persons and organisations requested to assist
Assistance to the aircraft at airport of departureNo

Yes, specify

Assistance between flights
NoYes, specify

Assistance on arrival at destination
NoYes, specify

Other assistance or valuable informationNo
Yes, specify8. Are any special in-flight arrangements needed, such as extra seat or special equipment? See Note 2 at the bottom of Page 2.
NoYes, specify at MEDA11-MEDA12 on page 2.

9. Is a stretcher needed onboard?
No

Yes. An escort with a medical training is required.

10. Name, age and qualifications of medically trained escort. If the escort has no medical training, write "Travel companion" and the person's name.
11. If the passenger is deaf and/or blind, is he or she being escorted by a trained dog?
NoYes

This text should be read by or to the passenger, dated and signed by him or her or on his or her behalf.
I hereby authorise all physicians and hospitals to provide the airlines with the information required by these airlines’ medical departments, for the purpose of determining myfitness for carriage by air. I therefore relieve these physicians of their vow of professional secrecy in respect to such information and agree to pay the physicians’ fees in this matter.
I am aware that, if accepted for carriage, my journey will be subject to the General Conditions of Carriage and the conditions of tariffs of the carriers concerned, and that thecarriers do not assume any special liability exceeding these conditions.

FINNAIR-1-14-0518

I am prepared, at my own risk, to bear any consequences which carriage by air may have on my state of health, and I release the carriers, their employees, servants and agentsfrom any liability for such consequences.
I agree to reimburse the carriers upon demand for any special expenditures or costs in connection with my carriage.
Passenger's or guardian's phone number and e-mail address
Place and datePassenger’s or guardian’s signature

If your medical condition/travel details change in any way prior to travelling, you are requested to contact Finnair Plc.

MEDIF
Confidential medical information form for air travel

Page 2For official
use only.

If you have a case reference number, attach the file to your case via this form. If
you don't have one, fill in a new form and attach the file to it.
This form should be completed by the attending physician.
Please answer all questions, marking an ‘x’ in the ‘Yes’ or ‘No’ boxes and using block letters or typing when completing the form. Fill in all boxes to avoid further enquiries

This form is intended to provide confidential information to enable the airlines’ Medical Clearance Services to assess if the passenger is fit to travel as indicated on Page 1. If the passenger
is accepted for travel, this information will permit the issuance of necessary instructions to ensure the passenger’s welfare, comfort and safety during the flight. Incomplete forms will be
returned and may cause a delay in the process. Please complete the form in capital letters using black ink.

MEDA01

Patient's full nameSexMale

Date of birthHeight (cm)

MEDA02

Attending physician's name, telephone, fax number and email address (necessary in case further information is required)

MEDA03

Diagnosis in detail, including vital signs (especially oxidation and Hb), present state briefly

Weight (kg)FemaleDate of first symptoms

Date of diagnosis, length of hospitalisation

MEDA04

Prognosis for the trip

MEDA05

Does the patient have a contagious or communicable disease?

No

Yes, specify

MEDA06

Psychiatric conditions

No

Yes

Is there a possibility that the patient will become agitated during the flight?

NoYes

Can the patient's behaviour be disturbing to other passengers?

No

Yes, specify

MEDA07

Can the patient use a normal aircraft seat with the seatback in the upright position when so required?

MEDA08Can the patient take care of his or her own needs onboard unassisted, including meals, visits to toilets etc? (See Note 1 at the bottom of the page.)
Yes

MEDA09Yes

No, specify

No, specify type of help needed

Does patient have normal bladder control?

Yes

No. If No, give mode of control

Does the patient need to be escorted?

Yes

No

Is the intended escort capable and prepared to provide all assistance including feeding, toileting and lifting as required?

Yes

No

PNR for escort (if different)
Is the arrangement proposed on Page 1 satisfactory, in your opinion?
Yes
MEDA10No, specify type of escort proposed by you

Chronic pulmonary condition

Yes

No

If yes, SpO2 on air and date taken:a) Has the patient had recent arterial blood gases?

YesNob) Blood gases were taken on

Room airOxygen

Liters per minute (LPM)

If yes, what were the results?

pCO2 (kPa/mm Hg)% Saturation

pO2 (kPa/mm Hg)
Date of testc) Does the patient retain CO2?

Yes

Has a Hypoxic Challenge Test been undertaken?

Yesd) Has his/her condition deteriorated recently?

YesNoNo

Date of testResultsNo

MEDA11 - a)Does the patient need any medication or does the patient need to use any special apparatus such as a respirator (See Note 1 and 2)?

MEDA12 - b)a) On the groundNo

Yes, specifyb) Onboard the aircraftNo

Yes, specify

Specify medication or apparatus (manufacturer, model and brand, battery or supply current, is apparatus needed also during takeoff and landing?)

MEDA13 - a)Does the patient need hospitalisation?

MEDA14 - b)a) During a long layoverNoYesb) Upon arrival at destination

No

Yes

Specify arrangements madeMEDA15

Other remarks or information in the interests of your patient’s smooth, comfortable and safe transportation
No

MEDA16

Yes, specify

Other arrangements made by the attending physician

Note 1
Cabin attendants are not authorized to give special assistance to particular passengers to the detriment of service to other passengers. Cabin attendants are trained only in first aid
and are not permitted to administer any injection or to give medication. Cabin crew are employed as food handlers and are therefore unable to assist with toileting needs.
Note 2
Any possible fees which are relevant to the provision of the above information and for carrier-provided special equipment shall be paid by the patient.
Place and date

Attending physician’s signature

Finnair Plc, Helsinki, Finland Business ID: 0108023-3 Address: Tietotie 9 A, 01530 Vantaa, Finland

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