HTML Preview Medical Doctors Note For Air Travel During Pregnancy Eng page number 1.
Doctor’s Note for Air Travel during Pregnancy
You must have your designated obstetrician complete this form to confirm that it is safe for you to fly on an aircraft.
This check list is to evaluate the patient passenger’s health status by aviation medical doctor of Korean Air, and will be
used for the patient passenger’s air transportation purposes only. We might contact the attending physician for further
information, in needed.
This document will be kept for 10 years, and you have the right not to agree. If you provide us inaccurate information,
authorization might not be issued for the passenger’s air travel.
If the obstetrician is unable to use this form, then the information may be included in the medical certificate or the
doctor’s note of the applicable hospital (medical institution).
1. Passenger and Travel Information
Name
Age
Flight Schedule
2. Birth History
Normal Delivery
□ None □ Yes ( times)
Preterm Delivery
□ None □ Yes
3. Information about Current Pregnancy
Gestational age (as of now)
weeks days
Single/Multiple pregnancy
□ Single □ Multiple ( Number of fetus: )
Expected Date of Delivery (EDD)
DD / MM / YY
Complication related to pregnancy
(premature rupture of membrane,
placenta previa, preterm labor, etc.)
□ None □ Yes ( )
Opinion about Air Travel
( including within 7 days of
return schedule )
□ Fit to travel □ Not fit to travel
□ Doctor’s confirmation needed before return flight
4. Advice or comments
Date : Hospital (specialist) :
License No. : Doctor’s name : (Sign)