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Medical Certificate of Fitness for Air Travel (MEDIF form)
This form is intended to provide confidential information to enable the airline Medical Doctor to assess the fitness for travel and provide for the
passenger’s special needs. It must be dated not more than one month prior to date of flight departure.
The physician attending the incapacitated passenger is requested to answer all questions.
Put a cross (X) in ‘Yes’ or ‘No’ boxes. Use BLOCK LETTERS or TYPEWRITER when completing this form.
ITEM 1
Passenger’s Name:
SEX:
AGE:
Address:
Email:
Phone(H):
Mobile:
Itinerary – Flight Details Mandatory
Booking Reference:
Flight No:
Date:
From:
To:
Flight No:
Date:
From:
To:
Note: Transfer from one flight to another requires LONGER connecting time.
To be completed by Attending Physician/Treating Doctor:
Name:
Address:
Email:
ITEM 2
Attending
Physician/Treating
Doctor
Name of Hospital or Clinic
(if relevant)
Business: HOME: Fax:
NATURE OF
INCAPACITATION:
Note:
Non autonomous pax must
be accompanied by an
able-bodied passenger
familiar with his/her needs
Medical Clearance required if patient non autonomous.
Can patient travel in a sitting position for the duration of flight?
NO YES
Whether infectious?
NO YES
Whether patient has full control of bowels & bladder?
NO YES
Diagnosis of
condition:
ITEM 3
Present Symptoms:
Whether patient displays suicidal tendencies or is subject to fits of violence?
NO YES