CONFIDENTIAL
Passenger Medical Clearance Form – Part 1••••

To be completed by the Passenger in English
Please answer ALL questions.
Please note that you will have to bear any associated charges made by your doctor for completing
this form. By providing the information requested in this form, you are waiving the confidentiality of
the information disclosed by your attending doctor.
This form must be returned to our Call Centre no less than 72 hours prior to the passenger’sscheduled departure time.

A

Passenger Details
Surname Name/First Name: _____________________________________
Date of Birth: _____________________

Gender: ______

Telephone: _____________________________

Email: _____________________________________________________________________

B

Itinerary
Booking Reference/ PNR(s): _____________________
Flight No.: __________

Date: __________

Origin: __________

Destination: _________

Flight No.: __________

Date: __________

Origin: __________

Destination: _________

Flight No.: __________

Date: __________

Origin: __________

Destination: _________

Flight No.: __________

Date: __________

Origin: __________

Destination: _________

Note – This form must be dated within 10 days of the initial outbound travel date. The same
form is also valid for passenger’s return journey if the return sector is within 14 days of thedeparture sector.

C

Do you need to use Portable Oxygen Concentrator (POC) on board?

No 

Yes 

If yes, please confirm and specify that: the POC is FAA approved.
 the POC has sufficient batteries to support at least 1.5 times of theflight’s duration
 all batteries carried on board must be packed in accordance with
relevant authority regulations and fulfilled the requirements for safety,
security and hazardous material. For details, please refer to our
website:[https://www.hkexpress.com/en-hk/plan/travel-information/controlledand-banned-items/]
Device number: _________________________________________
Weight and dimension: ___________________________________Name of manufacturer: ___________________________________PASSENGER’S DECLARATIONI hereby authorise _________________________________________________________ (name ofnominated doctor) to provide the airline with the information required by the airline for the purpose ofdetermining my fitness for carriage by air and in consideration thereof I hereby relieve that doctor of
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CONFIDENTIAL
his/her professional duty of confidentiality in respect of such information, and agree to meet suchdoctors’ 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 am prepared, at my own risk to bear any consequences which carriage by air
may have for my state of health and I release the carrier, its employees, servants and agents from any
liability for such consequences.
I agree to reimburse Hong Kong Express Airways Limited (“HK Express”) upon demand for any
fees or costs incurred in connection with my carriage. I further acknowledge and agree any costs
associated with this assessment and completion of the form shall be fully borne by me. (Where
needed, to be read by/to the passenger, dated and signed by him/her, or on his/her behalf)
I hereby consent to HK Express holding and using personal and/or medical details provided on this formand by my nominated doctor, and disclosing my personal and/or medical information to other airlines in
my itinerary and to third parties, such as medical professionals, airport and airline staff, government
bodies and border control authorities and service providers as appointed by HK Express for the
purposes of assessing and determining my fitness to travel and arranging necessary assistance, careand equipment for my travel arrangements.
I acknowledge that I may withdraw my consent to HK Express holding and using these details bycontacting the Data Protection Officer as set out in the privacy policy, but that this may mean that HK
Express cannot process the medical clearance and arrange the relevant assistance. I hereby consent
to my personal and/or medical data being processed, used and/or disclosed for the purpose set out
above.
For further information on how we process your personal information and contact details of the Data
Protection Officer, please read our privacy policy [https://www.hkexpress.com/en-hk/need-help/privacypolicy/].
Passenger’s Signature

Date

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CONFIDENTIAL
Passenger Medical Clearance Form – Part 2••••

To be completed by the Attending Doctor in English
Answer ALL questions
This form must be returned to our Call Centre no less than 72 hours prior to the passenger’sscheduled departure time.
This form must be dated within 10 days of the initial outbound travel date. The same form isalso valid for passenger’s return journey if the return sector is within 14 days of the departure
sector.

When completing this form, please keep in mind that air travel has some unique features which must be
considered to ensure a safe and comfortable flight. The principle factors to consider when assessing apassenger’s fitness for air travel are:
• Reduced atmospheric pressure: Cabin air pressure changes occur after take-off and before
landing and lead to gas expansion and contraction which may cause pain and pressure effects.
• Reduction in oxygen tension: The aircraft cabin is pressurised to an equivalent of 6,000-8,000
feet and oxygen partial pressure is approximately 20% less than on ground. Healthy passengers
have no problems at these altitudes, but passengers with anaemia or heart and lung conditions may
be at risk and require supplemental oxygen during air travel.
• Inaccessibility to advanced medical care: The aircraft cabin is a closed environment where
access to advanced medical care may not be possible for several hours. Our cabin crew is trainedin basic first aid and we do carry medical kits and heart defibrillators on board, but advanced medicalcare onboard is not possible. If a passenger has a medical condition that carry a high risk of requiringextraordinary medical assistance in-flight, they may not be accepted for air travel.
Detailed guidance is provided in Appendix 1. HK Express has considered IATA Medical Manual
Edition 11 in developing these guidelines.
Any costs associated with this assessment and completion of the form is at the passenger’s
expense.

A

Passenger Details
Surname Name/First Name: ____________________________________________________
Date of Birth: ____________________________

B

Gender: ______

Attending Doctor’s Information
Surname Name/First Name: ____________________________________________________
Address: ____________________________________________________________________________________________________________________________________________
Telephone No. (Business): ________________________
Telephone No. (Mobile): __________________________
Email: _____________________________________________________________________

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CONFIDENTIALC

Medical Diagnosis
Details of current medical conditions (including vital signs, symptoms and severity, treatment
and recent surgery): ____________________________________________________________________________________________________________________________________
Date of first symptoms: _________ Date of diagnosis: _________ Date of surgery: _________

D

Will a 25% to 30% reduction in the ambient partial pressure of oxygen

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

(relative hypoxia) affect the passenger’s medical condition? (Cabinpressure to be the equivalent of a fast trip to a mountain elevation of
2400 meters (8000 feet) above the sea level)

E

Stretcher needed on board?
Note - Stretcher service is not available on HK Express flightF

Intended Escort(a) Can the passenger comprehend and respond appropriately tosafety instructions from cabin crew and/or assist in their own
evacuation from the aircraft in an emergency?
(b) Can the passenger take care of his/her own personal needs onboard UNASSISTED (including meals, visit to toilet, administeringof medications etc.)? (*)

G

Can the passenger sit UPRIGHT in a normal aircraft seat during takeoff, landing and emergency?

H

Does the passenger have any contagious OR communicable disease?
If yes, specify: ______________________________________________________________________________________________

I

Would the physical and/or mental condition of the passenger cause asafety risk to other passengers or themselves?
If yes, specify: ______________________________________________________________________________________________J

Does the passenger need oxygen equipment in flight?
If yes, state rate of flow:
2 / 4 Litres per minuteContinuous? No / Yes

Note - you may bring a concentrator on board. However, oxygen cylinder is notallowed on board and no oxygen bottles could be arranged on board.

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CONFIDENTIAL

K

Does the passenger need any Portable Medical Electronic Devices on

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

board? And how critical are these apparatuses?
If yes, specify: ____________________________________________________________________________________________________
Note – only POC, CAPA and BiPAP are allowed to use on board; all medical
equipment must be battery operated and fulfilled dangerous goods regulations

L

Does the passenger medically need Portable Oxygen Concentrator(POC) on board?
If yes, please complete the following:
I verify that: (choose either one)
 the passenger has the physical and cognitive ability to operate thedevice; see and hear any alarms and respond appropriately.
 the passenger does NOT have the physical and cognitive ability tooperate the device; see and hear any alarms and respond
appropriately, but is accompanied by a passenger who can performthese functions.
The requirements for the use of the POC on board are: (choose eitherone) Continuous – during all phases of the flight, including taxi, take-off
and landing.
 Intermittent – during the flight, but not whilst taxing, take-off andlanding.
The oxygen flow rate for the POC is set at ________ litres per minute,considering the air pressure in the cabin under normal operating
conditions.

M

Does the passenger need any MEDICATION other than those selfadministered?
If yes, specify: ____________________________________________________________________________________________________Can it be administered by the escort?
Note – Our cabin crew are trained only in first aid and are not permitted to administer
any medication.

N

Does the passenger need HOSPITALISATION upon arrival?
If yes, indicate arrangements made or if none were made, indicate“NO ACTION TAKEN”________________________________________________________________________________________________________________
Note – the attending doctor is responsible for all arrangements

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CONFIDENTIAL
Cardiac conditions

O

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

(b) Complication? If yes, specify: _____________________________

No 

Yes 

(c) Test done? If yes, specify: _______________________________

No 

Yes 

(d) Can the patient walk 50 metres at a normal pace or climb 10-12

No 

Yes 

No 

Yes 

No 

Yes 

Does passenger suffer from an existing or chronic pulmonary condition?

No 

Yes 

(a) Has the patient had recent arterial gases?

No 

Yes 

(b) Does the patient retain CO2?

No 

Yes 

(c) Has his/her condition deteriorated recently?

No 

Yes 

(d) Can the patient walk 50 metres at a normal pace or climb 10-12

No 

Yes 

No 

Yes 

Does passenger suffer from Angina?
(a) Date of last episode: ______________(b) Is the condition stable?
(c) Functional class of the passenger?
No symptoms

Angina with strenuous efforts

Angina with light efforts

Angina at rest(d) Can the patient walk 50 metres at a normal pace or climb 10-12
stairs without symptoms?

P

Does passenger suffer from Myocardial infarction?
(a) Date: _____________________________

stairs without symptoms?

Q

Does passenger suffer from cardiac failure?
(a) Date of last episode: ______________(b) Is the patient controlled with medication?
(c) Functional class of the patient?
No symptoms

Shortness of breath with strenuous efforts

Shortness of breath with light efforts
Shortness of breath at rest
Pulmonary conditions

R(i) Date of exam: ____________(ii) If yes, arterial gases were taken on: Room air Oxygen(iii) if (ii) on oxygen, specify: _____________________________(iv) What were the results: pCO2 ___________ pO2___________
If no, saturation by pulse oximeter: _______________________

stairs without symptoms?
(e) Has the patient ever taken a commercial aircraft in these same
conditions?
(i) if yes, date: _________; any problem? ____________________
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CONFIDENTIAL
Psychiatric conditions

S

Does the passenger suffer from psychiatric conditions?

No 

Yes 

(a) Is there a possibility that the patient will become agitated during the

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

flight?
(b) Has he/she taken a commercial aircraft before after the diagnosis
was made?
(i) if yes, date: _________; Travel alone with escort
SeizureT

Does the passenger suffer from seizures?
(a) What type of seizures? __________________________________(b) Frequency/duration: ____________________________________(c) Date of last seizure: _____________________________________(d) Are the seizures controlled by medication?

Please note:(*) We are unable to provide any assistance for personal care needs such as feeding and elimination
functions, including assistance inside the lavatory. Additionally, cabin crew are trained only in first aid
and are not permitted to administer any medication.
Prognosis for the flight Fit to Travel Not Fit to Travel

Specify:

I confirm that I have received permission from my patient to communicate this information. I
certify that the above-named passenger is fit to travel on the proposed flights and in myopinion is capable of completing the flight safely, without requiring extraordinary medical
assistance during the flight.
I further certify that this person does not have any contagious disease that could directly place
another passenger or the crew at risk, or that would contravene relevant Quarantine or Public
Health Department regulations.
As a courtesy, HK Express may notify any doctor who clears a passenger for travel if the condition of
the passenger deteriorates in flight, or if the level of care required for that passenger results in aninterruption to normal operations.
Doctor’s Signature

Hospital/Clinic’s Stamp

Date

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CONFIDENTIAL
Appendix 1: Medical Clearance Guidelines
Diagnosis / Condition

Not suitable for travel

Comments for treating doctor’s
information

Cardiovascular and other Circulatory conditions
AnginaUnstable angina or angina withminimal exertion

Myocardial infarction Post-STEMI
and NSTEMI
Cardiac failure

Within last 7 days

Pacemaker or defibrillator
implantation
Angiography (Heart – Coronary
artery X rays)
Angioplasty with or without stent(Widening of arteries)
Cardiac surgery

24 hours

Thrombophlebitis of legs
DVT/ Pulmonary embolism

If active
Onset 4 days or lessStable on oral anticoagulants
Anticoagulants stable and PAO2
normal on room air

AnemiaHb less than 8.5 g/dl

Sickle cell disease

Sickling crisis in previous 9 days

If acutely anemic, Hb level should
be assessed more than 24 hrs.
after last blood loss, which musthave ceased.
Consider oxygen requirement.
Consider having oxygen available
if there has been recent a recent
sickling crisis

Acute heart failure or uncontrolledchronic heart failure

Must be stable and controlled withmedication.
No angina at rest
Must be stable
Adequate control is someone thatcan walk 50 meters or go up aflight of stairs on room air at a
normal pace without
breathlessness.
Otherwise, in-flight oxygen needs
to be considered

24 hours or less2 days or less9 days or less

Blood conditions

Respiratory conditions
Pneumothorax (air in the cavity
around the lung due to a puncture
wound or spontaneous)
Chest surgery

7 days or less after full inflation

Pneumonia

Acute, with symptoms

Tuberculosis

Untreated or non-responsive totreatment
If infectious
Supplementary oxygen needed at
ground level.
PO2 < 50mmHg
Unresolved recent exacerbation

COPD, emphysema, pulmonary
fibrosis, pleural effusion (fluid in thelung cavity) and hemothorax(Blood in the cavity around thelung) etc.
AsthmaMust have no air in chest cavity onchest X-ray

14 days or less

Recent severe attack within 48
hours

Fully resolved or, if X-ray signs
persist, must be symptom free
After at least two weeks ofappropriate treatment and withevidence of response to treatment
Supplementary oxygen may beneeded in flight.
Altitude studies may be neededMust be stable andRemind to carry usual prn
medication in carry-on baggage

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CONFIDENTIAL
Central Nervous System conditions
TIA (Transient Ischaemic Attack)
CVA (Stroke)

2 days or less3 days or lessGrand mal fit/epilepsy
Cranial surgery

Less than 24 hours or unstable
9 days or lessMust be stable
Must be self-sufficient, otherwise
escort is required
Cranium must be free of air

Gastro-intestinal conditions
GIT bleed

Less than 24 hours following a
bleed

Major abdominal surgery
Appendectomy
Laparoscopic surgery (Keyhole)
Investigative laparoscopy

10 days or less4 days or less4 days or lessLess than 24 hours

Endoscopic or clear evidence (i.e.
Hb has continued to rise to indicate
bleeding has ceased) Hb levelmust be sufficient for air travel

All gas must be absorbed
All gas must be absorbed

Ear, Nose and Throat conditions
Otitis media and sinusitis
Middle ear surgery

Acute illness or with loss of
Eustachian function
9 days or lessTonsillectomy

14 days or lessMust be able to clear ears
Must be able to clear ears

PsychiatricAcute psychosis

If unstable

Providing stable for 7 days. Travel
may be approved with suitable
medical escort

Penetrating eye injury

6 days or lessAny gas in globe must be
reabsorbed

Cataract surgery

Less than 24 hours

Corneal laser surgery

Less than 24 hours

Eye conditions

Pregnancy and new born
Miscarriage (threatened orcomplete)

With active bleeding

Must be stable, no bleeding and no
pain for at least 24 hours

New born

Less than 48 hours

Risk of hypoxia if respiratory
system not fully developed

Miscellaneous
Communicable diseases
Burns

During contagious stage of illness
If still shocked or with widespread
infection or greater than 20% total
body surface area

Plastic surgery

Terminal illness
Decompression

Must be medically stable and wellin other respects

Consideration needs to be given tocertain procedures, such as
abdominoplasty and thethromboembolic risk, andprolonged body weight pressure on
recently placed prostheses
or operated sites
If at risk of death during flight
3 days for the bends
7 days with neurological symptoms

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