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. Please submit the Medical Information Form by document submission form or fax at least 3 days
before departure.
・Files Submission Form: https://support.flypeach.com/hc/en-us/articles/360006510914

・FAX:+81-50-3737-9665

PATIENTS INFORMATION
AgeNameGender□ male□ female*Please write so that non medical personnel can understand.
Diagnosis in details
When did the firstsymptoms appear

For expecting mother

Date:（Estimated delivery date）（Date of Operations, if any）

Date:

DIAGNOSIS CONTENT
1 Prognosis for the flight(s)Can the patient use normal aircraft seat with the2 seatback placed in the Upright Position when sorequired?
(during take-off and landing)

1:Date:□Fit□Not Fit

2:Date:□Fit□Not Fit□ Yes□ No□ Yes （＊The patient must be fully knowledgeable in its use.）

Can the patient is fully capable/able to use lavatory,provide self-care (eat, drink…etc.) unattended
3without assistant from flight crew?

□ No, Must be accompanied by Physician or Nurse□ No, Must be accompanied by a person who is approved by Physician
Escort name 【Dose passenger need Oxygen equipment in flight?
4】□ Yes ➔ If “Yes”,Liters per minute :(ℓ/min)

□ No
□ Yes

Continuous use?

□ No
□ Yes ➔ <The Name of Medical Equipment>

5 Dose the patient need medical equipment in flight?

□ No<Manufacturer or Distributor><Product name / type or model number><Size / Type of Battery>

6 Does patient need any medication in flight?

□ Yes ➔ Specify:□ No

Specify more details, if necessary
7Prognosis as above. I will provide necessary information required by the airline's for the purpose of determining his/her fitness to travel by
air with consent of the patient.
Date of Submission:

PHYSICIAN
NAME (Signature)
Hospital Name
Telephone Number

Emergency Telephone
NumberCC-024-001© Peach Aviation Limited – 2024 All rights reserved

SPECIAL ASSISTANCE REQUEST【To be completed by the passenger or travel agent】

PATIENTS INFORMATION
AgeNameTelephone Number

Gender（Home）□male□female（Mobile）

E-mail Address
Itinerary

1.Date:Flight No.:

Travel segment(DEP-ARR): (―)

2.Date:Flight No.:

Travel segment(DEP-ARR): (―)

Personal Escort

Name:□Pysician □Nurse □Others（）

Personal Escort

Name:□Pysician □Nurse □Others（）

Do you need wheelchair?
1□ No□ Yes ➔ Please let us know your mobility condition in order for us to accommodate your needs□ Unable to walk, require wheelchair at all time
□ Able to walk but require assistant ascend or descend steps□ Able ascend or descend steps by own accord but unable walk long distance

Please tell us about your personal mobility assistant device, wheelchair.

2□ No wheelchair□ Personal wheelchair➔ 車椅子のタイプ□ はい□ Manual
□ 手動式

□ はい

➔ 車椅子のタイプ□ Electric/Battery-powered

はい➔ 車椅子のタイプ

い➔ 車椅子のタイプ□ Foldable□ Non-Foldabl□ Non-Spillable Battery (Wet-cell “sealed”)□ Dry Battery (NiCad, Ni-MH)□ Li-ion Battery*Please send "Wheelchair Check Form" if you require wheelchair assistant.
*Peach Aviation do not accept Battery-powered wheelchair with Spillable Battery (Wet-cell “non-sealed”).
3

Do you require wheelchair in cabin?

□ No

□ Yes

4

Do you require Oxygen Cylinder in flight?

□ No

□ Yes

➔ If yes, please send "Oxygen Cylinder Check Form".

5

Do you use Portable Oxygen Concentratorin flight?

□ No

□ Yes

➔ If yes, please send "Oxygen Cylinder Check Form".

Agreement

I here by 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 inconsideration 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.
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 agree to reimburse the carrier upon demand for any special expenditures or costs in connection with my carriage

Date:

Passengers signature:（or a Representative）
CC-024-002© Peach Aviation Limited – 2024 All rights reserved