medical format

7/24/2019 Medical Format

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Level 1 Tower C Global Business Park MG Road Gurgaon,122 002 IndiaT+91 124 406 2500 F+91 124 406 8536 goIndiGo.in

APPLICATION FOR CARRIAGE OF MEDICAL PASSENGERSDetailed Medical Certificate must accompany this completed form. Medical PassengerCompleted Application to be forwarded to the Medical Department DEL for approval.IndiGo does not provide any oxygen for prebooked medical passengers. Oxygencannot be carried by medical passengers.STRETCHER CASE.(Allowed only on selected flights.)SITTING CASE

Customers last name________________________

Customers first name________________________

IndiGo Flight No______ Date______________

Departure city__________________

Arrival city____________________

Permanent Address____________________________________________________

___________________________________________________________

________________________________

Departure contact telephone no___________

Arrival contact telephone no_____________

MEDICAL DETAILSTO BE COMPLETED BY PASSENGERSS TREATING DOCTOR:


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1) Doctors Name, Address, Tel / Fax No, Qualifications, Registration No___________________________________________________________________

___________________________________________________________________

2) Patients Name __________________________Sex ______ Age ______

3) Diagnosis & Date of onset 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

Nil / On Accustomed Exertion / At Rest

8) Details of ongoing medical treatment / any special comments regarding treatment onflight____________________________________________________________


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9) Does patient have full control of bowels / bladder? Yes / No

10) Can patient eat / drink unaided? Yes / No

11) Can patient use aircraft toilet unaided? Yes / No

12) Does patient require wheelchair? Yes / No

If yes which of the following

a) To aircraft steps b) To the cabin door c) To seat

13) Does patient require Doctor/Qualified Nurse/Non-Medical Escort? Yes / No

14) Is patient accompanied? Yes/ No

If Yes, by whom___________________

15) Have arrangements for Ambulance / Hospitalization made at departure/arrivalairports?

If yes, give details _____________________________

Have above details been specified to passenger? Yes / No

PASSENGER DECLARED FIT TO FLY

SIGNATURE: _________ STAMP: ____________ DATE:_______

Note: 1) The attendant should ensure that all items / medical equipment brought on tothe aircraft by the patient (needles, syringes, and unused medications) are removed atthe time the patient disembarks from the aircraft


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GUIDELINES FOR ASSESSING PATIENTS FITNESS FOR TRAVEL ON IndiGoWhen assessing a patients fitness for air travel, the effects of reduced atmospheric

pressure and consequent reduction in oxygen tension must be considered. Even inpressurized aircraft the cabin pressure will be equivalent to an altitude of 5000-7000feet.Although each case will be considered on its merit, the following conditions are generallyconsidered unacceptable for air travel:

a) Critical heart and respiratory conditions (eg decompensated cardiac patients /patients with severe valvular disease / unstable angina / severe asthma) areusually not permitted to fly. Patients with recent coronary occlusion withmyocardial infarction are not normally permitted to fly within 6weeks of onset.

b) Introduction of air into body cavities for diagnostic / therapeutic purposes within 7days of travel.

c) Mental illness without escort / sedation.

d) Severe cases of otitis media / sinusitis.e) Acute contagious / communicable diseases.f) Fractures of the mandible with fixed wiring of the jaws.g) Uncontrolled severe hypertension / diabetes mellitus with or without complications.h) Peptic ulceration with hemorrhage within 3weeks of travel , except when permitted

by the treating consultant.i) PostOperative cases within i) 10days of abdominal operations.

i i) 21days of chest surgery.j) Pregnancy beyond 32 weeks, postpartum females & newborns in the first week.k) Patients with deep vein thrombosis (DVT) should not fly till patient is stabilized on

anticoagulant theory and there are no pulmonary complications. Passengers with riskfactors for developing DVT should carry fitness certificates from the treating doctor.l) Patients with severe anemia (HB < 8.5 gm / dl) are not permitted to fly. However inexceptional cases, they may be permitted to fly with a specialists certificate.m) Patients in acute phase of cerebral infarction (stroke) of any etiology are generallynot permitted to fly within 3 weeks of onset.Please Note:1) Cabin attendants are trained in basic First Aid only and are not expected to render

special nursing care to critically ill cases. First Aid Kits carried onboard theaircraft do not contain syringes, special drugs or instruments. Cabin attendantsare not permitted to administer injections or open


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Physicians kits, which contain life saving drugs / equipment that can be opened only

under instructions of Registered Medical Practitioners.2) Patients with intravenous ( iv ) drips are not allowed to fly unless they go as

stretcher cases as there is no provision for IV drips stands onboard the aircraft.All cases on intravenous drips must be accompanied by a qualified nurse /doctor.

3) Any fee for the completion of this certificate or for further medical examinationrequested by IndiGo doctors for purpose of certification will be the responsibilityof the patient.

4) Due to security reasons, personal oxygen cylinders, oxygen concentrators, etc willnot be carried on board the aircraft. Any electronic medical equipment requiresclearance by Engineering & Security before it can be carried on board the

aircraft.5) All medical details requested must be completed and submitted at least 24-48hrs

in advance of the flight. Clearance must be received from the Regional companydoctors at the metros. The form should be accurately completed and clearlytyped. This form is transmitted by telex/fax, so all medical terms should be legibleand completed in black ink.

6) The IndiGo doctors decision regarding fitness of the patient to fly or therequirement of medical escort will be final. If at the time of embarkation thecondition of the patient deteriorates carriage may be refused. Any case whichIndiGo feels might jeopardize the safety or operation of the aircraft will not beaccepted. Patients with symptoms likely to cause distress or inconvenience to

other customers will not be accepted.

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