Declaration

This is to certify that…………………………………………………… (Name of Patient)

travelling in helicopter ………..……..……….. (Reg No.) from ………………..……………….
(departure) to ………………..………………. (destination) on date ………………..…… that-

1. I ……………………..……………………………….(person accompanying the patient),

is related to patient as …………………………………..(relation).
2. The approval from the doctor for the patient to travel by helicopter has
been taken and attached.
3. I the under signed is fully and completely responsible for the comfort of
the patient being air lifted by Helicopter.
4. I also understand that the Operator, Pilot, Company or the State Govt.
shall not be held responsible for any mishappening in concern with the
patient.

……………………………………….(Signature)
………………………………………. (Name)
……………………………………… (Date)