SpiceJet Health Declaration Form

SPICEJET APPLICATION FOR CARRIAGE OF MEDICAL PASSENGERS

(Form to be forwarded to medical department for approval 72 hours prior to departure)

STRETCHER CASE YES / NO

(Doctor to accompany patient during flight mandatory)

SITTING CASE YES / NO

REQUIRING OXYGEN YES / NO

PASSENGER/FLIGHT DETAILS:

Passenger’s Name : First Name

Permanent Address :

Contact number :

Departure City Arrival City

Flight requested SG Date From to

MEDICAL DETAILS- TO BE COMPLETED BY PASSENGER’S TREATING DOCTOR

(1) Doctor’s Name, Address, Tel/mob, qualifications, registration No

(2) Patient’s Name: M / F Age :

(3) Diagnosis & Date 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 please specify Nil On accustomed exertion At rest

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

(9) Requirement for Oxygen (O2 flow rate in litres/min) ** Yes No

a. Continuously throughout journey (at airport & during flight)

b. Continuously throughout flight only

c. As & when required

(10) Does patient have full control of bowels/bladder Yes No

(11) Can patient use aircraft toilet unaided Yes No

(12) Does patient require wheelchair Yes No

(13) Does patient require Doctor/ qualified Nurse Yes No

(14) Are arrangement for ambulance/hospitalization made at destination- if yes, give details

Have above details been specified to passenger Yes No

(15) PASSENGER DECLARED FIT TO FLY

**Please note that aircraft oxygen cylinder can deliver oxygen only at fixed rates of 2 or 4 litre/minutes

When assessing a patients 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 5000-7000 feet. Although each case will be considered on its merit, the following conditions are generally considered unacceptable for air travel.

1. No pax with intravenous cannula will be issued a boarding pass. If the pax has fitness to travel by air from treating doctor then the i/v cannula has to be removed before being issued boarding pass.

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

3. Introduction of air into body cavities for diagnostic/therapeutic purposes within 7 days.

4. Mental illness without escort/sedation.

5. Severe cases of otitis media/sinusitis.

6. Acute contagious/ communicable diseases, (eg. chicken pox, viral conjunctivitis).

7. Fracture of the mandible with fixed wiring of the jaws.

8. Uncontrolled severe hypertension / diabetes mellitus with or without complications.

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

10. Post-Operative cases within i 10 days of abdominal operations. ii 21 days of chest surgery.

11. Pregnancy beyond 36 weeks, postpartum females & newborns in the first week.

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

13. Patients with severe anemia (Hb<8.5gm/dl) are not permitted to fly. However in exceptional cases, they may be permitted to fly with specialists certificate.

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