APPV-MEDIF FORM- 2017 - V3 - FOR PDF …

BCDEWHEELCHAIR NEEDED?Own wheelchairCollapsiblePower driven?Categories are *WCHR *WCHS *WCHCW heelchair Category:H1 Arrangement for delivery at airportof DEPARTURES pecify:H2 Arrangement for assistance atCONNECTING POINTSS pecify:H3 Arrangement for meeting at airportof ARRIVALS pecify:H4 Other requirements or relevant informationSpecify:K SPECIAL IN-FLIGHT ARRANGEMENTS NEEDED such as: special meals, special seating, leg-rest, extra seat (s), special equipment, etc.(See Note* at the end of PART 2 overleaf)FREMEC /(FR EMEC Number)(Sex)(Age)G AMBULANCE NEEDED?Spe cify destination address:FBattery Type(spillable?)Specify ambulance company contact:L(Issued by)(Val id until)*WCHR = passenger cannot walk well, but can use stairs, *WCHS = passenger cannot going up and down stairs, *WCHC = passenger cannot walk at all.

3.1 Patient C. Underlying disease If yes, where? If yes, Will this patient take the medications (noted above) during flight? NOTE * Please attached OFFICIAL medical summary or currently medical report, FIT to FLY certificate and test result.

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