Medical Information Form (MEDIF) PART 2 | MEDIF No:255060 “To be carpeted by the PHVSICIAN ATTENDING the incapaciaied pamsenger REQUIREMENTS for Transpertatio ‘wheelchair Needed? Others? WeHR wens He Steecher 5) | eubator EDR O1 | Pain’ Family Naren Fo wo CAR | aaa Tle Baines Mole MEDICAL DATA: DIAGNOSIS in deta Date of fist symptoms: | ate af cagnosie: eps 02 Date of operation Expecied date of delivery val Si oP [no oe PROGNOSIS or the ight Navane es oe sage non cole Contagious and. a wepa os | Comasieusand Would the physical anor mental condo ofthe pain be elt cause ves or @hcomfon wo er passenges? | EDA 06 mo he ae ly cae aes | Yes] NoC] —_spety rca oy SAM atlont use normal ireraf sat wih eat bet placed nthe upright poston when so requ? eon og [Cin patent take core of hirer needs onbord unassisted? tai AOS Teste Yes Ne Vist tole Yee) Na Wtobe ESCORTED, by whort? Doctor|) oe —) Rasp Therapati= Nansen] Pastngerwaveing done Orheripleaeapectd. | Hf no, state travel companion or proposed escort by you OXYGEN” equlpme oss the patent ne in figh? (FYES, please atts rate of flow) Continuous Yee Now [Litres Per Minute tciwren tian) — Specify MDA | Dossthe patient ned any MEDICATION, other than sell-administered, andlor the use of special apparatus such as respirator, incubator, ventilator, nebulizer et? ae a taery aerate equipment on bears must bey oro, pu A) Ontheground whileattheavport) Yee Nol) Specly 8) On board the aircraft Ye NotI Specify ‘Doss the patient need HOSPITALISATION, (FVES, msicate arongement made, or none were made, indicate "No action taker") |B) Upon arrival ot destination Ye No=l Speciy een wy [SABE ems frmaon i he nes of your patient oat and confortable wanspareation ‘Other arcangerents made by the Atending Physician [have read, understood and hereby agree to the conditions ofthe MEDIF form | aonding Physician’ Signature & Starmp Pace Date ‘Qatar Airway Mosieal Examiner Remarks ‘Anproved fone way) [—) Approved Wulljaurney) Rejected Need Deiais I | Swexcher Iweuhate 1 | Disper Pamper Sign & Stamp | Nerse Wheelehai nyse Pi Bassinet 3Medical Information Form (mEDiF) Other Important Information: £8) Wheelchairs can be provided at most airports if notice is given, 1b) Any case that Qatar Airways consi by Qatar Airways sult n jeopardizing the safety or operation of the aircraft will ot be accepted the fact that the med ation the condition of Je may have to be refus ©) Particular attention is draw and completed. fat t then the air carr al detalls given atthe front of this form must be accurately typed ssenger is not as good as the medical detals provided, 4) To ensure that your patient is accepted for carriage, i is important that all medical terms provided by the attending physician must be easily readable €) Wheelchairs with spill able batteries are “Dangerous Goods" and are permitted on passenger aircraft only under certain canditions which can be checked from the aiine, In addition certain countries may impose specific restrictions 4) For preanancy cases, the Attending Physician must specify "Single/Multiple” and "Complicated/Uncomplicated” in Diagnosis im details within MEDA 03 9) Mentally Deficient passengers. No MEDIF & Medical Report required ifthe passenger has a pre-approved Frequen Medical Card (FREMEC) or in stable condition 1) incase of pregnancy, please specify age of gestat Expectant mother has to be "Fit to forthe time covering the ion and if tis uncomplicated single or multiple J complicated pregnancy. sntire journey with ne intended/voluntary stopover at the transit point, Stopover is permissible provided the entire period of air travel is within the acceptable number of gestational weeks (not over 32 weeks far Multiple Pregnancy and not aver 35 weeks for single pregnancy). Equipment ] ‘Additional Information / Restriction 208 Lites per Minute (LPM) Mask + Standard - Adule-size depesable oxygen therapy mask + Options ~ Child-siae therapeutle mask Boeing NSW (154 / 60 He and 220 118A / 50 He