TO

FROM

Attention:

Sender: Caribbean Airlines Special Services

Fax No:

Fax No: 1 800 944 8999 US/Canada

E-mail:

Fax No: 1 868 625 1025 All Other Countries

E-mail: medas@caribbean-airlines.com

Company Ph.:

Tel No: 1 800 920 4225

Total No. of pages (including this page): 4

Date:

*If you do not receive the number of pages as stated above, please contact us so it can be resent.
This passenger has chosen to fly with Caribbean Airlines. At the time of the booking inquiry, the information provided has prompted us
to ask this passenger to have the attached Caribbean Airlines Medical Advice (MEDA) Form completed by the passengers medical
practitioner. This form is intended to provide confidential information to enable the airline to assess the passengers fitness to travel and
to issue any necessary directives designed for the passengers trip.
It is important that Caribbean Airlines receives the completed MEDA Form no later than 14 days prior to the passengers scheduled
departure date whereupon we will assess the passengers fitness to fly. In some cases we may ask for additional information.
Please find attached a copy of the Medical Advice (MEDA) Form which must be STAMPED AND SIGNED by the passengers Medical
Practitioner. Please note that any costs associated with this assessment and completion of the form is at the passengers expense.
You are asked to pay particular attention:
DIAGNOSIS - ITEM 3 OF THE MEDICAL INFORMATION SHEET PART 1 AND
PROGNOSIS FOR THE TRIP - ITEM 5 OF THE MEDICAL INFORMATION SHEET PART 2.
Should you require any clarification with respect to completing this form, please do not hesitate to contact us.
The form must also be signed by the passenger and faxed/e-mailed to Caribbean Airlines. The passenger must present the original form
at check-in

Passengers Name
Reservation Record Locator

Itinerary

Thank you for your co-operation.

Caribbean Airlines Special Services Department

MEDICAL ADVICE FORM (MEDA)

HANDLING INFORMATION
Answer ALL Questions Put a cross (X) in Yes or No boxes.
Use BLOCK LETTERS or ALL CAPS when completing this form.

DISTRIBUTION
1. Reservations
2. Airport
3. In-Flight
4. Passenger

.....

1.

Last name / First name / Title

2.

Passenger name record (PNR) .

3.

Proposed itinerary ...................

Airline(s), flight number(s) ...
Class(es), date(s), segment(s) ...

4.

Nature of disability ....

5.

Intended escorts

Yes

No

Name ....

Title...

Age ....
PNR if different .
Yes

Medical qualification

No

Language spoken
6.

7.

Wheelchair needed

Yes

No

Wheelchair categories

WCHR (Ramp)

WCHS (Stairs)

Own wheelchair

Yes No

Collapsible WCOB

Yes

Wheelchair type

WCBD (Dry Cell Battery)

Meet and assist

Yes

WCHC (Cabin)

No
WCBW (Wet Cell Battery)

WCMP (Manually Powered)

No

If designated person, specify contact ...

8.

Special inflight arrangements needed Yes No

If yes, specify type of arrangements (special meal, extra seat, special seating) .....................
Specify equipment (FAA Approved Personal Oxygen Concentrator, etc.) ..

PASSENGERS DECLARATION

I HEREBY AUTHORISE ..
(NAME OF NOMINATING PHYSICIAN)
To provide the airline with the information required by the airlines medical departments for the purpose of determining my fitness for carriage by air and in
consideration thereof I hereby relieve that physician of his/her professional duty of confidentiality in respect of such information and agree to meet such physicians
fee in connection therewith.
I take note that if accepted for carriage, my journey will be subject to the general conditions of carriage/tariffs of the carrier concerned and that the carrier does not
assume any special liability exceeding those conditions/tariffs.
I am prepared at my own risk to bear any consequences which carriage by air may have for my state of health and I release the carrier, its employees, servants
and agents from any liability for such consequences.
I agree to reimburse the carrier upon demand for any special expenditure or costs in connection with my carriage.
(Where needed to be read by/to the passenger, dated and signed by him/her or on his/her behalf.)

Place: .. Date: .. Passengers Signature: ....

Medical Information Sheet Part 1

TO BE COMPLETED BY THE ATTENDING PHYSICIAN
This form is intended to provide CONFIDENTIAL information to enable the airlines MEDICAL Departments to assess the fitness of the passenger to travel. If the passenger is acceptable, this information will permit
the issuance of the necessary directives designed to provide for the passengers welfare and comfort.

1.

Patients name ...

Date of Birth ..... Sex .. Height . Weight ....

2.

Attending physician ...

E-mail ..
Telephone (mobile preferred), indicate country and area code Fax ..

3.

Diagnosis (including date of onset of current illness, episode or accident and treatment, specify if contagious)
...
Nature and date of any recent and/or relevant surgery ..............................................

4.

Current symptoms and severity ..

.

5.

Will a 25% to 30% reduction in the ambient partial pressure of oxygen (relative hypoxia) affect the passengers medical condition? (Cabin pressure
to be the equivalent of a fast trip to a mountain elevation of 2400 metres (8000 feet) above sea level) Yes

6.

a. Anemia Yes

b. Psychiatric and seizure disorder

Yes

No If yes, see Part 2

c. Cardiac condition

Yes

No If yes, see Part 2

d. Normal bladder control

Yes

No If no, give mode of control ..

e. Normal bowel control

Yes

No

f. Respiratory condition

Yes

No If yes, see Part 2

h. Oxygen needed in flight?

Yes

No If yes, specify how much ........................

No If yes, specify 2 LPM 4 LPM Other ...

Continuous

Emergency Only

Escort
a. Is the patient fit to travel unaccompanied?

Yes

No

b. If no, would a meet-and-assist (provided by the airline to embark and disembark) be sufficient? Yes
c. If no, will the patient have a private escort to take care of his/her needs onboard?
d. If yes, who should escort the passenger?

9.

Yes

No

No

Doctor Nurse Other

e. If other, is the escort fully capable to attend to all the above needs?
8.

Not sure

No If yes, give recent result in grams of hemoglobin ..

g. Does the patient use oxygen at home? Yes

7.

No

Additional clinical information

Yes

No

Mobility
a. Able to walk without assistance

Yes

No

b. Wheelchair required for boarding

to aircraft to seat

Medication list

10.

Other medical information ...

Medical Information Sheet Part 2

TO BE COMPLETED BY THE ATTENDING PHYSICIAN

1.

CARDIAC CONDITION
a. Angina Yes

No

When was last episode? ..

Is the condition stable?

Yes

No

Functional class of the patient?

No symptoms

Angina with important efforts Angina with light efforts

Angina at rest

Can the patient walk 100 metres at a normal pace or climb 10 -12 stairs without symptoms?

Yes

No

Date ...

Yes

No

Yes

No

If yes, give details ..

Stress EKG done? Yes

No

If yes, what was the result? ..Metz

b. Myocardial infarction
Complications?

If angioplasty or coronary bypass, can the patient walk 100 metres at normal pace or climb 1012 stairs without symptoms?
Yes
c. Cardiac failure

No
Yes

No

When was last episode? ..

Is the patient controlled with medication? Yes

No

Functional class of the patient?

No symptoms Shortness of breath with important efforts Shortness of breath with light efforts Shortness of breath at rest
d. Syncope

Yes

Investigations?
2.

No

Last episode

Yes

No

If yes, state results ...

Yes

No

CHRONIC PULMONARY CONDITION

a. Has the patient had recent arterial gases?

Yes

b. Blood gases were taken on: Room air

Oxygen LPM

If yes, what were the results ..pCO2

No

.. pO2

Saturation .....................................................................
c. Does the patient retain CO2? Yes

Date of exam.....................................................................

No

d. Has his/her condition deteriorated recently?

Yes

No

e. Can the patient walk 100 metres at a normal pace or climb 10-12 stairs without symptoms?
f. Has the patient ever taken a commercial aircraft in these same conditions?

Yes

Yes

No

No

If yes when? .
Did the patient have any problems? .
3.

PSYCHIATRIC CONDITIONS Yes

No

a. Is there a possibility that the patient will become agitated during flight
b. Has he/she taken a commercial aircraft before

Yes

If yes, date of travel?

4.

SEIZURE Yes

Yes

No

No
Did the patient travel alone escorted?

No

a. What type of seizures? .

b. Frequency of the seizures ...
c. When was the last seizure? .
d. Are the seizures controlled by medication?
5.

PROGNOSIS FOR THE TRIP

Good

Yes

No

Poor

Physician Signature ..

PLACE STAMP HERE

Date ........

Note: Cabin attendants are not authorised to give special assistance (e.g. lifting) to particular passengers, to the detriment of their service to other passengers. Additionally, they are trained only in
first aid and are not permitted to administer any injection, or to give medication. Important: Fees, if any, relevant to the provision of the above information and for carrier-provided special equipment
are to be paid by the passenger concerned.