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Medical Certificate Of Fitness For Air Travel
Medical Certificate Of Fitness For Air Travel
R.O. 286/260416
Yes No
MEDICAL CERTIFICATE OF FITNESS TO FLY
This Medical Certicate 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 y.
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:
Emergency Contact Name
(e.g. family member or doctor):
Valid date range
(max. 6 months’ range):
Contact No.:
Medical Practitioner’s Declaration
Please tick the following boxes as appropriate:
The patient is able to sit upright unassisted.
The patient is able to look after themselves in-ight including the:
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:
the safety instructions;
emergency procedures; and
all instructions as directed by the crew.
The ying is not likely to cause the patient to require emergency medical attention.
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.
Travel Carer required because:______________________________
The patient’s condition is not contagious/infectious.
Oxygen Requirements
The patient requires supplemental oxygen during the ight.
If yes, the following must be completed:
- The patient may adjust the oxygen ow setting to a maximum of _________________,
as needed during ight, recognising the possible changes in cabin pressure during ight.
- 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 ight.
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 ight.
- Other information:
Note: If oxygen is required in ight, 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 (www.rex.com.au) may also be used. The patient must ensure that they have sufcient oxygen for their ENTIRE journey.
Additional medical information/comments:
Based on the above, I hereby declare that the patient is t to travel by air with Regional Express on the date(s) above with
the above conditions fullled.
Medical Practitioner Name:
Signature / Date / Stamp:
ID or Provider No.:
Contact No.:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
I have examined the patient and have made the following assessment of the medical condition:
Medical Certificate Of Fitness For Air Travel Previous Page
source: rex.com.au
Medical Certificate Of Fitness For Air Travel
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