MEDICAL INFORMATION FORM (MEDIF) 【To be completed by the attending physician】
The attending physician is requested to answer all questions. Enter a check mark(✔) in the appropriate "Yes" or "No" boxes, and/or give precise and concise answers.
Note 1 Please write so that non-medical personnel are able understand.
Note 2 Cabin Attendants are not authorized to provide personal care services, such as assistance in using lavatory facilities, with eating and drinking etc. Additionallythey are not authorized to administer medical care service.
Patient’s InformationAgeNameGender
Diagnosis in details
Note 1
When did the firstsymptoms appear(Date of Operation if any)

１２３４

For expecting mother(Estimated dateof delivery)(Day/Month/Year)

Prognosis for the flight(s)Can the patient use normal aircraft seatwith the seatback placed in the UprightPosition when so required?
※Stretcher is not available.
Can the patient take care of his/her
personal needs (lavatory, eat, drink etc.)
without assistant? Note 2
Can the patient travel alone?
Note 2Fit□ Not Fit□

Yes□

No□

Yes□

No□

(Day/Month/Year)

Prognosis for the Return FlightFit(if any)□ Not Fit□

If “No”, Specify name and details of Escort.

Yes

□

No□
If “Yes”, Specify.

５
Does the patient need medical equipment
in flight? Note 2※Oxygen bottle is not available.

■The name of Medical Equipment：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿_

Yes

□

No□

■Product name/Model number：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿___■Type of Battery/Size：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿_＿___

６

７

Does patient need any medication inflight?

Yes□

No□

If “Yes”, indicate arrangements made.

We would appreciate any general comment about the patient's condition and suggestion for the proposed air travel.

I will provide necessary information required for the purpose of determining his/her fitness to travel by air as above with consent of the patient.
PhysicianDate
Name(Signature)

Hospital Name

Address

Telephone

Emergency

NumberNumber(Day/Month/Year)Necessary Arrangement Request 【To be completed by the passenger】
Passenger
AgeName
GenderPhone Number(Mobile Phone)
Itinerary
Departure Date：

Flight No：ZG

Portion：fromtoDeparture Date：

Flight No：ZGPortion：fromtoEscort
NameAge□Physician □Nurse □Other(）

NameAge□Physician □Nurse □Other(）１

Do you need wheelchair at the airport？
No2□ Yes □Category:□ Requires assistance to/from the cabin seat. (WCHC)□ Cannot ascend/descend steps, but able to walk in the cabin. (WCHS)□ Can ascend/descend steps, but requires wheelchair for walking long distance. (WCHR)

Are you travelling with your own wheelchair? ※No□ Yes □Wheelchair Size:
Weight：kg

Width(W)：cm

Depth(D)：cm

Height(H)：cm※If you have a collapsible
wheelchair please input the size
when it is collapsed.

Wheelchair Type:□Collapsible□Manual□Non-Collapsible□Electric/Battery-powered□Lithium-ion Battery*Is the battery Removable?

□ Yes□ No□Dry Battery(NiCad, Ni-MH)□Wet Battery(Gel,Sillicon)※

The number of Lithium-ion batteries which can be carried onboard is limited.

※Please check wheelchair at the counter.

３
Do you use electric medical device in flight? (POC etc.)

No□ Yes □□Non-Spillable Battery□Spillable

If “Yes”, please inform Contact Center of the details of the electric medicaldevice in advance in order to confirm whether it can be used in flight.

Agreement

I hereby authorize ____________________________________________________ (Name of nominated attending physician) to provide the airlines with the information,required by those airline's medical department for the purpose of determining my fitness for carriage by air and in consideration thereof, I hereby relieve that physician
of his/her professional duty of confidentiality in respect of such information and agree to meet such physician's fees in connection therewith.

Date:

Passenger(or a Representative) signature: