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Name&Famili name: age:
sex: Origin:
destination: contact phone:
medical history:
final diagnosis:
Date of diagnosis:
Contagious And Communication Disease?
Is the patients condition likely to be a source of discomfort to other passengers (color, appearance, conduct)?
Transfering to the Airplane:
Position of the patient onboared:
Does the patient needs special care onboard?
If your answer to the previous question is Yes, please choose the appropriate care.
Oxygen Demand:
Does the patient needs ambulance on destination?
Does the patient needs hospitalization on destination?
Suggestions (Diet, Medication, ...):
It is
Attending Physician of the Patient
Accept the responsibility of the above mentioned information.
Contact phone of the physician:
Signature of the Attending physician:
Considerations of the airline trustee physician for carriage of the patient:
Sig. of airline trustee physician:
-This form is valid for 48 hours after clearance of the airline trustee physician.:
- Cabin attendance are traines only in FIRST AID and NOT PERMITED to administer any injection or to give medication.