Regional Express Medical Certificate Of Fitness To Fly

MEDICAL CERTIFICATE OF FITNESS TO FLY

This Medical Certificate must be completed in full, and produced at check-in and at each embarkation, by any passenger who has a medical impairment

which may impact on his/her suitability to fly.

Boarding may be denied if this form is not completed in full or at the sole discretion of a Rex agent or crew even when this form is produced.

Name of Patient:

Valid date range

(max. 6 months’ range):

Emergency Contact Name

(e.g. family member or doctor):

Contact No.:

Medical Practitioner’s Declaration

I have examined the patient and have made the following assessment of the medical condition:

Please tick the following boxes as appropriate:

The patient is able to sit upright unassisted.

Yes

No

The patient is able to look after themselves in-flight including the:

Yes

No

•

self administration of medication and/or oxygen as required;

•

consumption of food (crew will assist with the opening of packets if required);

•

use of toilet facilities (crew may assist passengers to/from the toilet door.

Flight Attendants are not permitted to handle urine-draining equipment).

The patient is able to understand and follow, without assistance:

Yes

No

•

the safety instructions;

•

emergency procedures; and

•

all instructions as directed by the crew.

The flying is not likely to cause the patient to require emergency medical attention.

Yes

No

If the patient is unable to meet any of the above requirements, they will be required to travel with a Carer.

Please tick below to indicate if a Travel Carer is required.

Yes

No

Travel Carer required because:______________________________

The patient’s condition is not contagious/infectious.

Yes

No

Oxygen Requirements

The patient requires supplemental oxygen during the flight.

Yes

No

If yes, the following must be completed:

- The patient may adjust the oxygen flow setting to a maximum of _________________,

Yes

No

as needed during flight, recognising the possible changes in cabin pressure during flight.

Yes

No

- The patient and/or Carer can appropriately see, hear and respond to any

applicable alarms.

- The patient requires the use of oxygen at all times, before, during and after flight.

Yes

No

This includes the use of oxygen while in the airport terminal, during take-off, landing

and while moving throughout the cabin of the aircraft; OR

- The patient requires the use of oxygen only during flight.

Yes

No

- Other information:

Note: If oxygen is required in flight, only the BOC Oxycare Travel Pack, Supagas Airline Travel Bag or Air Liquide Travel Pack is permitted. Only C size oxygen bottles are permitted. An approved

oxygen concentrator as listed on the Rex website ( ) may also be used. The patient must ensure that they have sufficient oxygen for their ENTIRE journey.

Additional medical information/comments:

Based on the above, I hereby declare that the patient is fit to travel by air with Regional Express on the date(s) above with

the above conditions fulfilled.

Medical Practitioner Name:

ID or Provider No.:

Signature / Date / Stamp:

Contact No.:

R.O. 286/260416