MEDICAL FORM

APPLICATION FOR CARRIAGE OF PASSENGER ON A STRETCHER

Detailed Medical Certificate must accompany this completed form for approval from AirAsia India
Medical Department.

AirAsia India does not provide oxygen and oxygen cannot be carried by passenger travelling on a
stretcher.

STRETCHER CASE

Guest last name : _____________________________

Guest first name : ____________________________________________________________ _

ID / Passport No : __________________________________

AirAsia India Flight No: ____________ ____ Date : _________________________ __

Departure Station : ________________________________

Arrival Station : ______________ _______________

Permanent Address : _ _________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Departure contact telephone no. : _____________________________________ ___________

Arrival contact telephone no. : __________________________________________ _____

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 MEDICAL DETAILS – TO BE COMPLETED BY PASSENGERS’S TREATING DOCTOR:

1) Doctor’s Name, Address, Tel / Fax No, Qualifications, Registration No

___________________________________________________________________________

___________________________________________________________________________

2) Patients’ Name : ______ Sex: ____ Age: _____

3) Diagnosis & Date of onset of illness : ____________________________________________

4) Is the disease contagious or infectious in any form? Yes / No

5) a) Present Symptoms _______________________________________________________

_______________________________________________________

b) Prognosis during flight ____________________________________________________

____________________________________________________

6) Vital Parameters (Pulse, BP, Temperature, Respiratory rate, Level of Consciousness)

• Normal / Abnormal (Please Specify) _____________________ ________

7) Dyspnoea

Nil / On Accustomed Exertion / At Rest

8) Details of ongoing medical treatment / any special comments regarding treatment on flight

_________________________________________________________________________

_________________________________________________________________________

9) Does patient have full control of bowels / bladder? Yes / No

10) Can patient eat / drink unaided? Yes / No

11) Can patient use aircraft toilet unaided? Yes / No

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12) Does patient require wheelchair? Yes / No

If yes which of the following

a) To aircraft steps
b) To the cabin door
c) To seat

13) Does patient require Doctor/Qualified Nurse/Non-Medical Escort? Yes / No

14) Is patient accompanied? Yes/ No

If Yes, by whom __________________________________________________

(Accompany details: Name/Contact):

15) Have arrangements for Ambulance / Hospitalization made at departure/arrival airports?

If yes, give details __________________________________________________

Have above details been specified to passenger? Yes / No

PASSENGER DECLARED FIT TO FLY

SIGNATURE: __________ STAMP: __ DATE:_ __________

Note: 1) The attendant should ensure that all items / medical equipment brought on to the aircraft by
the patient (needles, syringes, and unused medications) are removed at the time the patient disembarks
from the aircraft.

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GUIDELINES FOR ASSESSING PATIENT’S FITNESS FOR TRAVEL ON AirAsia India

When assessing a patient’s fitness for air travel, the effects of reduced atmospheric pressure and
consequent reduction in oxygen tension must be considered. Even in pressurized aircraft the cabin
pressure will be equivalent to an altitude of 5000-7000feet. Although each case will be considered on its
merit, the following conditions are generally considered unacceptable for air travel:

a) Critical heart and respiratory conditions (e.g. decompensated cardiac patients / patients with severe
valvular disease / unstable angina / severe asthma) are usually not permitted to fly. Patients with
recent coronary occlusion with myocardial infarction are not normally permitted to fly within 6weeks
of onset.

b) Introduction of air into body cavities for diagnostic / therapeutic purposes within 7days of travel.

c) Mental illness without escort / sedation.

d) Severe cases of otitis media / sinusitis.

e) Acute contagious / communicable diseases.

f) Fractures of the mandible with fixed wiring of the jaws.

g) Uncontrolled severe hypertension / diabetes mellitus with or without complications. h) Peptic

ulceration with haemorrhage within 3weeks of travel , except when permitted by the treating
consultant.

i) Post – Operative cases within i) 10days of abdominal operations.

ii) 21days of chest surgery.

j) Pregnancy beyond 34 weeks, postpartum females & new-borns in the first week.

k) Patients with deep vein thrombosis (DVT) should not fly till patient is stabilized on anticoagulant
theory and there are no pulmonary complications. Passengers with risk factors for developing DVT
should carry fitness certificates from the treating doctor.

l) Patients with severe anaemia (HB < 8.5 gm / dl) are not permitted to fly. However in exceptional
cases, they may be permitted to fly with a specialist’s certificate.

m) Patients in acute phase of cerebral infarction (stroke) of any etiology are generally not permitted to
fly within 3 weeks of onset.

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Please Note:
1) Cabin attendants are trained in basic First Aid only and are not expected to render special nursing
care to critically ill cases. First Aid Kits carried on-board the aircraft do not contain syringes,
special drugs or instruments. Cabin attendants are not permitted to administer injections or open
Physician’s kits, which contain life-saving drugs / equipment that can be opened only under
instructions of Registered Medical Practitioners.

2) Patients with intravenous (iv) drips are not allowed to fly unless they go as stretcher cases as there
is no provision for IV drips stands onboard the aircraft. All cases on intravenous drips must be
accompanied by a qualified nurse / doctor.

3) Any fee for the completion of this certificate or for further medical examination requested by AirAsia
India doctors for purpose of certification will be the responsibility of the patient.

4) Due to security reasons, personal oxygen cylinders, oxygen concentrators, etc. will not be carried
on board the aircraft. Any electronic medical equipment requires clearance by Engineering &
Security before it can be carried on board the aircraft.

5) All medical details requested must be completed and submitted at least 24-48hrs in advance of the
flight. Clearance must be received from the company doctors. The form should be accurately
completed and clearly typed. This form is transmitted by fax, so all medical terms should be legible
and completed in black ink.

6) The AirAsia India doctor’s decision regarding fitness of the patient to fly or the requirement of
medical escort will be final. If at the time of embarkation the condition of the patient deteriorates
carriage may be refused. Any case which

AirAsia India feels might jeopardize the safety or operation of the aircraft will not be accepted. Patients with
symptoms likely to cause distress or inconvenience to other customers will not be accepted.

AirAsia India Doctor

SIGNATURE:_______________________ STAMP: ___________________ DATE:_________________

AirAsia India Engineer

SIGNATURE:_______________________ STAMP: ___________________ DATE:_________________

AirAsia India Security

SIGNATURE:_______________________ STAMP: ___________________ DATE:_________________

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