westjet medical information form, v7

This form is interactive. You can type your information into the form and then print before you sign. If you fill in by hand, be sure to print legibly; this will help avoid processing delays.

Fees for completion of this form are the responsibility of the patient.Please fill in completely; accommodation decisions will not be made with incomplete forms. Submit completed forms to WestJet by e-mail to [email protected] or by fax to 1-866-737-1202

P A T I E N T I N F O R M A T I O N

Last name (provide name exactly as shown on travel identification) First name Middle name

Birthdate MM/DD/YYYY Gender

Female Male

E-mail Contact number

Address Town/City

Province/State Postal code/ZIP Country

WestJet OP Number (only if you have had a previous accommodation approval)

WestJet ID (optional but will aide in our provision of some services)

Intended date of travel MM/DD/YYYY Flight origin Flight destination

A L T E R N A T E C O N T A C T

Please provide an alternate contact (can be parent, guardian or decision maker) if patient is a child or cannot advocate for themselves. The alternate contact will have access to this medical information, may speak on patient’s behalf for follow up questions and may be provided details regarding patient’s on board accommodation.

Name Relationship

E-mail (if different than patient’s) Contact number (if different than patient’s)

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mailto:meddesk%40westjet.com?subject=

Patient name

P R E V I O U S T R A V E L H I S T O R Y

Have you ever flown on a commercial aircraft in the medical condition indicated on this form?

No Yes

How did you travel? Alone Accompanied

When?

Have you suffered from any medical complications that required medical intervention during a commercial flight?

No Yes

If yes, please provide date and details.

P A T I E N T C O N S E N T A N D A G R E E M E N T

I _________________________________ consent and authorize my treating medical professionals to provide and discuss the information on this form, other medical information or my previous travel history with WestJet as required to facilitate my safe air travel. This consent and authorization extends to any medical professional holding information relevant to my assessment by WestJet, or any support organization arranging travel on my behalf. I consent to the collection and retention of the medical information on this form for the purposes of facilitating travel, with the understanding that this medical information will be kept confidential in accordance with WestJet’s Privacy Policy.

I understand that if approved, WestJet will provide appropriate accommodations to me. I agree to provide updated medical information for any significant change(s) to my health, and to abide by the terms of any medical accommodation including personal attendant requirements and restrictions applicable to travel companions.

Signature (patient/guardian/or decision maker) Date MM/DD/YYYY

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Patient name

P H Y S I C I A N D E T A I L S

All remaining must be completed by a medical physician.

Physician name License number

Province/Country of registration Town/City

E-mail (optional)

Contact number Fax Date of first visit MM/DD/YYYY

Is the patient regularly in your care? No Yes

If there is another medical professional or support organization with whom WestJet may need to discuss information relevant to your patient’s fitness to fly please provide their information below. Include all occupation(s) and contact information (e-mail/phone numbers)

Physicians are required to complete mandatory section 4, initial and date all pages where indicated. Please select the applicable statement for your patient and complete as directed.

My patient is requesting:

Confirmation they are medically fit to fly, an allergy buffer zone, or a seating accommodation

Complete section 1

An extra seat for obesity Complete sections 1 and 2

A personal attendant Complete sections 1 and 3

An accommodation inflight to or from the United States

Other/Medical exemptions

Complete section 4

Complete sections 1, 4 and appropriate appendix

Section 4 is mandatory.

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Patient name

S E C T I O N 1 : F I T T O F L Y I N F O R M A T I O N

Section 1 is required for all patients, except those travelling to/from the U.S. Note: Although section 1 is not required for travel to/from the U.S., we recommend that it is completed to ensure safety for travel and assess if onboard accommodations are required.

Diagnosis Date of onset MM/DD/YYYY

Current symptoms and severity

Treatment/prescribed medication(s)

Recent, relevant or planned surgery/sedation No Yes

Nature Date MM/DD/YYYY

Currently hospitalized? No Yes

If yes, will be discharged to Home Facility

Date of discharge MM/DD/YY

AllergiesComplete only if your patient has a severely debilitating/life threatening allergy that requires a buffer zone accommodation on board the aircraft.

Not applicable (skip) Yes - Please complete the following

Allergen Symptom

Hives

Sneezing

Anaphylaxis

Asthma attack

Allergen Symptom

Hives

Sneezing

Anaphylaxis

Asthma attack

Physician initials Datev7.2 of 12

Patient name

Pulmonary

Not applicable (skip) Yes - Please complete the followingCondition Type

Does the patient have shortness of breath?

No Yes, with light efforts

Yes, with major efforts Yes, at rest

Has the patient deteriorated recently? No Yes

Details

Oxygen saturation

% L/min Continuous oxygen Pulse setting Room air

Does the patient use oxygen at home? No Yes

Will your patient require oxygen inflight? No Yes

Max L/min required during flight Max pulse setting during flight

For usage of a personal oxygen concentrator, please see westjet.com/oxygen for documentation requirements and restrictions. Patient supplied gaseous oxygen cylinders are prohibited on board all WestJet operated flights. WestJet does not supply oxygen for purchase on board our aircraft.


https://westjet.com/oxygen

Patient name

Cardiac

Not applicable (skip) Yes - Please complete the followingCondition Type

A. Angina

No Yes

Date MM/DD/YYYY

The patient’s condition is Stable Unstable

If unstable, please select one

No symptoms Angina at rest Angina w/major effort Angina w/ minor effort

B. Myocardial infarction

No Yes

Date MM/DD/YYYY

Complications Stable Unstable

Angiogram/Angioplasty Angiogram AngioplastyProcedure date MM/DD/YYYY

C. Cardiac failure

No Yes

Class 1-4

Details

D. Syncope

No Yes

Last episode MM/DD/YYYY

Investigations No Yes Undiagnosed

If investigated, result/cause


Patient name

Seizures

Not applicable (skip) Yes - Please complete the followingType

Frequency Date of last seizure MM/DD/YYYY

Are the seizures stable and controlled by medication? No Yes

Is oxygen or suction required to manage the seizure? No Yes

Cognitive/behavioral or psychiatric


Condition type/explain

Is there a possibility the patient’s condition will deteriorate during flight? No Yes

If yes, please explain

Please complete section 3 if an attendant would mitigate patient’s condition during flight.

Seating accommodations


Please indicate the seating accommodation and provide medical rational to support.


Patient name

S E C T I O N 2 : S E A T I N G A C C O M M O D A T I O N S F O R O B E S I T Y


Height

cm

Weight

kg

Waist around umbilicus

cm

Maximum girth around hips above gluteal fold

cm

Waist

Hips

S E C T I O N 3 : A S S I S T A N C E R E Q U I R E M E N T S


Once on board the aircraft, is your patient capable of:

Taking medication unaided? No Yes

Using the toilet unaided (once inside the lavatory)? No Yes

Managing their meals unaided? No Yes

If no, what assistance is required? Feeding Opening containers Set-up/orientation

Does your patient require a medically qualified attendant in order to travel? No Yes

Indicate additional or specific assistance needs your patient requires on board the aircraft:


Patient name

Wheelchairs, transfers and medical equipmentDo not use this form to request the use of a wheelchair. See westjet.com/wheelchairs for advance notice requirements and more information.


Will your patient require a wheelchair for

Distance Transfer from door aircraft to their seat At all times

Can your patient ascend/descend steps? No Yes

Can your patient self-transfer to/from a wheelchair to the seat of the aircraft? No Yes

Can your patient stand, pivot and weight bear? No Yes

If transfer assistance is required, can your patient be transferred using a mechanical lift? (Note: WestJet cannot transfer patients exceeding 200kg/440lbs)

No Yes

If no, why?

Please list any medical equipment your patient will require during the flight

Additional Medical Information


Please provide additional medical information you feel is relevant to your patient’s situation or accommodation request.


https://westjet.com/wheelchairs

Patient name

S E C T I O N 4 : M A N D A T O R Y F O R A L L P A T I E N T S

If your patient consents to providing WestJet with additional medical information, we strongly recommend you complete section 1. This information may help identify further onboard accommodations that may be required to ensure a safe flight.

Prognosis for a safe flight with no extraordinary medical attention

Good Poor if the patient has any of the following:a) An unstable medical conditionb) A medical condition that may worsen at altitude in a hypoxic environmentc) May require medical assistance or emergency medical equipment during flight

Is your patient fit to fly? No Yes

Fused or immobilized lower limb

Does the patient have a fused knee or immobilized lower limb? No Yes

If yes, we may request further medical information to provide this accommodation. You may opt to complete section 1: fit to fly information.

Communicable disease

Does the patient have an active communicable infection/disease that can be transmitted or pose a direct threat to the health and safety of other individuals during the normal course of their travel?


Condition type/explain

Are there any precautions needed to prevent the spread of infection or disease during the course of their travel?

No Yes

Explain

P H Y S I C I A N ’ S C O N S E N T

By signing this form, I understand that I am providing information which WestJet will use to determine my patient’s ability and/or accommodations needed to travel safely. I accordingly certify that all of the information I have provided is complete, true and accurate to the best of my knowledge. If only section 4 is completed, this must be dated within 10 days of travel and travel must be completed within 10 days of approval.

Signature Datev7.2 of 12

Patient name

A P P E N D I X A : C O V I D 1 9 V A C C I N E E X E M P T I O N P H Y S I C I A N A S S E S S M E N T F O R M

Requests for vaccine exemption will only be considered upon completion and presentation of this form along withapplicable sections to our Medical Information Form in advance of scheduled flight of departure for domestic flights within Canada and for outbound flights from Canada only. Incomplete forms and unsigned forms will not be considered.

If approved for a temporary COVID-19 vaccine exemption, you will be required to present results of a negative COVID-19 molecular test result taken within 72 hours of your scheduled departure time. Note: temporary exemption requests from the requirement to have a valid COVID-19 test result are not supported through this process.

Part A: Objective Medical InformationTo be completed by physician or nurse practitioner.

I, _________________________________, hereby confirm that the person to be exmpted above is unable to be vaccinated due to one of the following reasons:

Certified medical contraindictions to full vaccination against COVID-19 with an mRNA vaccine, as based on the recommendation of the National Advisory Committee on Immunization. The following are certified medical contraindiction as of October 22, 2021:

a) A history of anaphylaxis after previous administration of an mRNA COVID-19 vaccine (and noting that most people who experienced a severe immediate allergic reaction after a first dose of an mRNA COVID-19 vaccine can safely receive future doses of the same or another mRNA COVID-19 vaccine after consulting with an allergist or another appropriate physician); and/or

b) A confirmed allergy to polyehtylene glycol (PEG) which is found in the Pfizer-BioNTech and Moderna COVID-19 vaccines (note that if a person is allergic to tromethamine which is found in Moderna, they can receive the Pfizer-BioNTech product)

Condition is Permanent TemporaryExpected recovery date MM/DD/YYYY

Medical reasons for delay of full vaccination against COVID-19 as described by the National Advisory Committee on Immunization. As of October 22, 2021, this may include:

a) A history of myocarditis/pericarditis following the first dose of an mRNA vaccine; and/or

b) An immunocompromising condition that requires waiting to vaccinate when immune response can be maximized (i.e. waiting to vaccinate when immunocompromised state or medication is lower)

Condition is Permanent TemporaryExpected recovery date MM/DD/YYYY


Patient name

Part B: AttestationTo be completed by physician or nurse practitioner.

Healthcare provider name (please print) Specialty and License number

I am a

Physician (M.D.) licensed to practice medicine in a jurisdiction of Canada

Nurse Practitioner licensed in a jurisdiction in Canada

By signing below, I affirm that I have reviewed the current NACI contraindications to Covid-19 Vaccination and affirm that the stated contraindication(s) is consistent with established national standards for vaccination practices. As per the applicable Interim Order Respecting Certain Requirements for Civil Aviation Due to COVID-19, a person who provides information to a carrier that is known to be false or misleading may also be subject to an administrative monetary penalty or other enforcement action, including prosecution.

Signature (Physician/Practitioner) Date MM/DD/YYYY

Physician office stamp required

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westjet medical information form, v7

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