Date modified: 01 Mar, 2015

Thai Airways International Public Company Limited

MEDIF
PART 1 INCAPACITATED PASSENGERS HANDLING ADVICE (INCAD) Category
To be completed HANDLING INFORMATION - PART 1
by Answer ALL questions - put a cross (x) in YES or NO boxes.
SALES OFFICE/AGENT Use BLOCK LETTERS or TYPEWRITER when completing this form.

NAME / INITIALS / TITLE

A Last name: ......................................................................... First name: ............................................. Title: ..................... AGE: .......................

1st Flight No.: TG................... From: ................................... To: .............................

PROPOSED ITINERARY Date: ......................................... PNR: .....................................................................
(airline (s), flight number (s), Transfer from one flight
B class (es), date (s), segments (s), to another often requires
2nd Flight No.: TG................... From: ................................... To: ............................
reservation status of continuous LONGER connecting time
Date: ......................................... PNR: .....................................................................
air journey)

MEDICAL No
C NATURE OF INCAPACITATION: CLEARANCE
REQUIRED? Yes

IS STRETCHER NEEDED ON BOARD?

D (all stretcher cases MUST be escorted.)
No Yes Request rate if unknown

Last name:................................................. First name: ..........................................

INTENDED ESCORT (Name, sex, age,
professional qualification, segments
E if different from passenger)
if untrained, state TRAVEL COMPANION
Sex: .................................... Age:......................... Doctor / Nurse / Parmedic
PNR: ...............................................
For blind and/or
Last name:................................................. First name: ..........................................
deaf, state if
Sex: .................................... Age:......................... Doctor / Nurse / Parmedic escorted by trained dog.
PNR: ...............................................

Wheelchairs with spillable batteries

WHEELCHAIR NEEDED? No OWN Power Battery Type arerestricted articles and are
Collapsible
wheelchair driven? (spillable?) permitted on passenger aircraft
F Categories are Yes only under certain conditions,whic
No No No No can be obtained from the airline(s).
*WCHR *WCHS *WCHC
In addition, certain countries
Wheelchair Category: Yes Yes Yes Yes
may impose specific restrictions.

To be arranged by AIRLINE
AMBULANCE NEEDED? No No Specify ambulance company contact: Request
G rate(s) if
Yes Yes Specify destination address: unknown

OTHER GROUND If yes, SPECIFY below and indicate for each item: (a) the ARRANGING airline or other
H No
ARRANGEMENTS NEEDED organisation, (b) at whose EXPENSE, and (c) CONTACT addresses/phone numbers where
Yes appropriate, or whenever specific persons are designated to meet/assist the passenger.
1 Arrangements for
delivery at airport No Yes Specify
of DEPARTURE

2 Arrangements for
assistance at No Yes Specify
CONNECTING POINTS

3 Arrangements for
meeting at airport No Yes Specify
of ARRIVAL

4 Other requirements
or relevant information No Yes Specify

SPECIAL IN-FLIGHT If yes, DESCRIBE and indicate for each item: (a) SEGMENT(s) on which
ARRANGEMENTS NEEDED, No Yes required, (b) airline-ARRANGED or arranging third party, and (c) at whose
such as:special meals, special expense. Provision of SPECIAL EQUIPMENT such as oxygen etc.,
seating,leg-rest, extra seat(s), always requires completion of PART 2 overleaf.
K special equipment, etc.
(See Note* at the end of
PART 2 overleaf)

DOES PASSENGER HOLD A FREQUENT If yes, add below FREMEC date to your reservation requests
TRAVELLERS MEDICAL CARD VALID No Yes If no (or if additional data needed by carrying airline(s)).
FOR THIS TRIP? (FREMEC) have physician in attendance complete PART 2 hereof.

FREMEC /
L
(FREMEC Number) (Issued by) (Valid until) (Sex) (Age) (Incapacitation)

(Incapacitation continued) (Limitations)

*WCHR = passenger cannot walk well, but can use stairs; *WCHS = passenger cannot going up and down stairs; *WCHC = passenger cannot walk at all
 Date modified: 01 Mar, 2015

Thai Airways International Public Company Limited CONFIDENTIAL

For official use only.
PART 2 M E D I C A L I N F O R M A T I O N S H E E T - M E D I F

This form is intended to provide CONFIDENTIAL information to enable the airlines' MEDICAL Please return
Departments to assess the fitness of the passenger to travel. If the passenger is acceptable, this the completed form to
To be completed information will permit the issuance of the necessary directives designed to provide for the passenger's
by welfare and comfort.
ATTENDING The PHYSICIAN ATTENDING the incapacitated passenger is requested to ANSWER ALL QUESTIONS.
PHYSICIAN Enter a cross "x" in the appropriate "yes" or "no" boxes, and/or give precise concise answers.
IN CASE OF HIV POSITIVE PATIENT, THE LATEST CHEST X-RAY RESULT SHOULD BE
ATTACHED TO THIS MEDICAL INFORMATION SHEET.
COMPLETING OF THE FORM IN BLOCK LETTERS OR BY TYPEWRITER WILL BE APPRECIATED. ADDRESS of TG issuing office

MEDA01 PATIENT'S NAME, INITIAL(S), SEX, AGE:

ATTENDING PHYSICIAN Name: Address:

MEDA02 - Name & Address
- Telephone Contact Business: Home:

MEDICAL DATA:
- DIAGNOSIS and TREATMENT in
details
MEDA03

- Latest vital signs: BP= / PR= RR= TEMP= SpO2= Date

- Day/month/year of first symptoms: Date of diagnosis:

MEDA04 PROGNOSIS for the flight (s): GOOD (No Problems Anticipated) GUARDED (Potential Problems) POOR (Problems Likely)

MEDA05 - Contagious AND communicable disease? No Yes Specify:

- Would the physical and/or mental condition of the patient
MEDA06 be likely to cause distress or discomfort to other passengers? No Yes Specify:

- Can patient use normal aircraft seat with seatback placed

MEDA07 in the UPRIGHT position when so required? Yes No

- Can patient take care of his own needs on board Yes No

MEDA08 UNASSISTED * (INCLUDING meals, visit to toilet, etc)?
If not, type of help needed

- If to be ESCORTED, is the arrangement Yes No

MEDA09 satisfactory to you?
If not, type of escort proposed by YOU
- Does patient need OXYGEN ** equipment Litres Yes
MEDA10 in flight? (if yes, state rate of flow). No Yes per Minute Continuous No
(a) on the GROUND while at the airport(s):
- Does patient need any MEDICATION *
MEDA11 other than self-administered and/or No Yes Specify:
the use of special apparatus
such as respirator, incubator,etc. **? (b) on board of the AIRCRAFT:
MEDA12 No Yes Specify:

(a) during long layover or nightstop at CONNECTING POINTS en route:

- Does patient need HOSPITALISATION?
MEDA13 (if yes, indicate arrangements made No Yes Action
or, if none were made, indicate
"NO ACTION TAKEN")
(b) upon arrival at DESTINATION
MEDA14 No Yes Action

- Other remarks or information

MEDA15 in the interest of your patient's None Specify if any**
smooth and comfortable
transportation.
- Other arrangements made by
MEDA16 the attending physician.

NOTE (*): Cabin attendants are NOT authorized to give special assistance to IMPORTANT: FEES, IF ANY, RELEVANT TO THE PROVISION OF THE ABOVE
particular passengers, to the detriment of their service to other INFORMATION AND FOR CARRIER-PROVIDED SPECIAL
passengers. Additionally they are trained only in FIRST AID and are EQUIPMENT (**) ARE TO BE PAID BY THE PASSENGER
NOT PERMITTED to administer any injection or to give medication. CONCERNED.

Place : SAMITIVEJ SUKHUMVIT HOSPITAL Date: Attending Physician's Signature:

PASSENGERS DECLARATION
I HEREBY AUTHORIZE.................................................................................................................................................................
(name of nominated physician)
to provide the airlines with the information required by those 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 fees 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 agree to reimburse the carrier upon demand for any special expenditures 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 : SAMITIVEJ SUKHUMVIT HOSPITAL Date : Passengers Signature :

 MEDICAL INFORMATION SHEET
Thai Airways International Public Company Limited CONFIDENTIAL
This transportation purposes only. We, the Aero Medical Center of THAI AIRWAYS, give medical authorization for the
PART 3 passengers air travel, depending on the following documentation provided by you, the attending physician. Please make sure
To be completed the attending physician of the patient fills out all applicable items below for patients safe and healthy journey. If needed, we
will contact to the attending physician for further information. form is only to evaluate the patient passengers health
By Attending status, and will be used for the patient passengers air
Physician

3.1 Patient Name: Age: Male / Female Height(cm): Weight(kg):

A. Mental status
Alert Drowsy Stupor Semi-coma Coma GCS Score : E V M

Pupil size ___/___ mm (react sluggish not react)

Respiratory

B. Physical
Cardiovascular
examination
Neurological

C. Underlying
disease
Yes No If yes,(Please specify)
3.2
C. Hospitalization Did this patient have surgery / Medical procedure? Yes No
Operation/ If yes, name of operation / procedure
Procedure
Is there any complication after surgery / procedure? Yes No
If yes, please explain

Has/Had this patient been admitted to the hospital recently? Yes No

If yes, where? ICU General ward ER Other(please specify)

Hospitalization date : Discharge date:
Medication
3.3 Does this patient take any medications? Yes No

If yes, Orally IV or IM Other *Medication list must provide in Medical report

Will this patient take the medications (noted above) during flight? Yes No
Medical Equipment
3.4
During Flight
None
IV line Foley catheter Nasogastric tube Chest tube Endotracheal tube Tracheostomy
Suction kit Oxymeter Infusion pump Nebulizer Portable oxygen concentrator
Ventilator (Setting: )

Brand and Model: Splint/Cast

Other
* In case of medical equipment use, Please notice the equipment model type to THAI AIRWAYS reservation center.
* Any necessary supply of electricity should be from battery power only.
* IV fluid should be prepared in plastic bag.
NOTE *Please attached OFFICIAL medical summary or currently medical report, FIT to FLY certificate and test result
(Blood test or Image test, etc.) related the patient's disease with hospital stamp.

Available contact number: Date: Attending Physician signature:

(Hospital Stamp)

APPROVED REJECTED NEED DETAILS

Remark:
THAI AIRWAYS

PHYSICIAN
APPROVAL

TG Medical Approval ( )

Date modified: 01 Mar, 2015