Medif Form Qatar Airways – Fill Out and Use This PDF

MEDICAL INFORMATION FORM

(MEDIF)

PART I:

To be accomplished by Sales Office/Agent

PLEASE COMPLETE THE FORM IN BLOCK LETTERS

Airlines’

Name of Passenger:

Sex:

Age:

Weight:

Height:

Ref. code

MEDA 1

MEDA 2

Address:

Contact No(s):

ROUTING

CARRIER

FLT. NO.

CLASS

DATE

BOOKING REF.

PROPOSED

ITINERARY

Information written in this form shall be CONFIDENTIAL.

FOR PAL PHYSICIAN’S USE ONLY

The PHYSICIAN ATTENDING to the incapacitated passenger is requested to ANSWER

ALL QUESTIONS (Enter a cross “X” in the appropriate “yes” or “no” box and/or

DATE:____________________

give precise answers).

Clearance for air travel DENIED

IMPORTANT:

(**)Fees, if any, relevant to the provision of the information below, including but not limited

Okay for BOOKING; To report to PAL Medical Clinic

to OXYGEN BOTTLES, STRETCHER and/or AMBULANCE are to be paid by the

4 hours before check-in time.

passenger concerned.

NOTE:

CLEARED for air travel until_______________

(*)Cabin Attendants are NOT authorized to give special assistance to a particular

passenger to the detriment of their services to other passengers. Additionally, they are

trained only to render FIRST AID and are NOT PERMITTED to administer any injection

_____________________________________________

or to give any medication.

PRINTED NAME & SIGNATURE OF PAL PHYSICIAN

Name:

MEDA 4

ATTENDING PHYSICIAN

Contact Nos.

Business:

Home:

MEDICAL DATA

Date of Diagnosis:

MEDA 5

Diagnosis in detail:

> ILLNESS:

___________

(including vital signs)

> SURGERY: ___________

> INJURY :

___________

Wheelchair category : WCHR

WHEELCHAIR needed?

NO

YES

Collapsible?

NO

YES

Own wheelchair?

NO

YES

WCHC

MEDA 6

Battery type, spillable?

NO

YES

Power driven?

NO

YES

WCHS

Wheelchairs with spillable batteries are “dangerous goods” and are permitted on passenger aircraft only under certain conditions,

which can be obtained from the airline(s). In addition, certain countries may impose specific restrictions

MEDA 7

Is STRETCHER needed on board the aircraft? **

NO

YES

If YES, type of escort required:

Liters per

Type of escort required:

MEDA 8

Does patient need OXYGEN on board? **

NO

YES

minute:

Continuous?

YES

NO

No. of OXYGEN

tanks reqd:

MEDA 9

PROGNOSIS for the trip:

GOOD

FAIR

POOR/GUARDED

MEDA 10

Contagious/communicable disease?

NO

YES

Specify:

MEDA 11

Is patient’s condition likely to be a source of discomfort

NO

YES

Specify:

to other passengers? (Odor, appearance, conduct)

MEDA 12

Can patient use normal aircraft seat with seatback placed

NO

YES

Remarks:

in UPRIGHT position when required?

MEDA 13

Can patient take care of his own needs on board UNASSISTED

NO

YES

If YES, type of help needed:

( including meals, visit to the toilet, etc.)?

Does patient need any MEDICATION* other than self-administered

A) on the GROUND while at the airport(s):

MEDA 14

NO

YES

Specify:

and/or the use of special apparatus such as respirator, incubator, etc.**?

B) aboard the AIRCRAFT:

MEDA 15

(Clearance with PAL Safety & Environment Department required)

NO

YES

Specify:

MEDA 16

A) during long layover or nightstop at CONNECTING POINTS en route?

Does patient need HOSPITALIZATION?

NO

YES

Action:

(If YES, indicate arrangements made or,

B) upon arrival at DESTINATION:

if NONE were made, indicate “NO ACTION TAKEN”)

MEDA 17

NO

YES

Action:

MEDA 18

Other remarks or information in the interest of your

NONE

YES

Specify:

patient’s smooth and comfortable transportation?