MEDICAL CLEARANCE FORM - Travel Service

1 Travel Service MEDICAL CLEARANCE FORM F/GOU/GOM/3 13 MAY2016 page 1 / 2 HEALTH STATUS OF PASSENGER / ZDRAVOTN STAV CESTUJ C HO:(To be filled in by physician / Vypln no o et uj c m l ka em)If any of the following conditions apply to your patient, please complete this MEDICAL CLEARANCE Form. / Jestli e se n kter z n e uveden ch podm nek t kaj Va eho pacienta, vypl te pros m tento Formul potvrzuj c zp sobilost k p eprav .Diagnosis / Diagn za:(Please cross applicable / Za krtn te pros m) Heart attack (within 21 days of intended Travel ) / Infarkt myokardu (21 dn a m n p ed pl novanou cestou) Stroke (within 10 days of intended Travel ) / Mozkov mrtvice (10 dn a m n p ed pl novanou cestou) Infants newborn babies (within 7 days of birth) / erstv narozen d ti (7 dn a m n po porodu) Decompression sickness / Dekompresn (kesonov ) nemoc Pneumothorax (within 14 days of resolution) / Pneumotorax (14 dn a m n od ud losti) Requirement for stretcher / Po adavek na nos tka Inability to sit upright / Neschopnost sed t vzp men Head injury (within 14 days of intended Travel ) / Poran n hlavy (14 dn a m n p ed pl novanou cestou)

2 Fractures (except for uncomplicated fractures of upper limbs and fingers of upper limbs) / Zlomeniny (krom nekomplikovan ch zlomenin horn ch kon etin a prst horn ch kon etin) Plaster cast (except for plaster cast on upper limbs and fingers of upper limbs) / S dra (krom s dry na horn ch kon et n ch a na prstech horn ch kon etin) Deep vein thrombosis / Hlubok iln tromb za Psychiatric disorder (must Travel with an escort sitting in adjacent seat) / T k du evn porucha (mus cestovat s doprovodem, kter m zaji t no vedlej sedadlo) Any serious or acute infectious disease (incl. chickenpox), please specify / Jak koliv v n nebo akutn infek n nemoc (v etn plan ch ne tovic), pros m specifikujte: Other diagnosis (please specify) / Jin diagn za (pros m specifikujte): MEDICAL CLEARANCE FORM / FORMUL POTVRZUJ C ZP SOBILOST K P EPRAV INFORMATION ABOUT PASSENGER: / INFORMACE O CESTUJ C M.

3 (To be filled in by passenger / Vypln no cestuj c m)Passenger s name / Jm no cestuj c hoFlight Number / slo letuDate of Flight / Datum letuDuration of flight / Doba trv n letuReservation code in case of electronic bookingsRezerva n k d v p pad elektronick rezervaceFrom > To / Odlet z > P let doStreet & Number / Ulice a sloCity & ZIP code / M sto a PS Country / Zem Email / E-mailPhone no. / Kontaktn tel. sloTRAVEL Service MEDICAL CLEARANCE FORM F/GOU/GOM/3 13 MAY2016 page 2 / 2 Prognosis for the flight(s) / Progn za pro let(y):(Please cross applicable / Za krtn te pros m) This is to certify that the above named passenger is fit to Travel on the proposed flight(s) without any extra Service or assistance.

4 Potvrzuji, e v e jmenovan cestuj c je schopen leteck p epravy na uveden ch letech bez po adavku na speci ln slu by nebo asistenci. This is to certify that the above named passenger is fit to Travel on the proposed flight(s) but needs extra Service or assistance. Required extra Service or assistance is specified in attached MEDICAL Information Form (MEDIF). Potvrzuji, e v e jmenovan cestuj c je schopen leteck p epravy na uveden ch letech, ale vy aduje speci ln slu by nebo asis-tenci. Po adavky na speci ln slu by nebo asistenci jsou specifikov ny v p ilo en m zdravotn m formul i (MEDIF). This is to certify that the above named passenger is not fit to Travel on the proposed flight(s).

5 Potvrzuji, e v e jmenovan cestuj c nen schopen leteck p epravy na uveden ch CLEARANCE FORM / FORMUL POTVRZUJ C ZP SOBILOST K P EPRAV Physician s name / Jm no l ka e:Address / Adresa:Qualification / Obor :Phone no. / Telefon:Date / Datum:Signature / Podpis:This form must be returned to: / Tento formul mus b t odesl n: Tour Operator (applicable for clients of Tour Operators) / Cestovn kancel i (plat pro klienty cestovn ch kancel ) or/nebo Travel Service Group (Smart Wings) Customer Care Department (applicable for all other clients) / Odd len p e o z kazn ky skupiny Travel Service (Smart Wings) (plat pro v echny ostatn klienty). Travel Service Group (Smart Wings) Customer Care Department contact details /Kontakty na Odd len p e o z kazn ky skupiny Travel Service (Smart Wings):Email: CLEARANCE FORM is valid up to 14 days from the date of POTVRZUJ C ZP SOBILOST K P EPRAV je platn po dobu 14 dn od data vystaven.