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The customer who is using
Please enter the name, age and gender.
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- Name of the customer (patient) (Entry example: Taro Nikko)
- Age (Entry example: 51)
- Gender (Entry example: Male)
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Please enter the name of the medical institution and the name of the doctor
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- Name & medical institution name or specialty (Entry example: Tennozu Hospital, Ichiro Suzuki)
- Address (Entry example: 2-4-11 Higashi Shinagawa, Shinagawa-ku)
- Telephone number for the medical institution (Entry example: 03-5460-xxxx)
- Emergency contact
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Name of the illness, condition
Please enter in detail so that it is easy to understand.
Please also fill in the English name.
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- Diagnosis (illness name) & condition (Entry example: Influenza)
- Date that the symptoms began, or date of the surgery (Entry example: March xx, 2017)
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Please be sure to enter the suitability for air travel
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- Progress (prognosis) and the suitability of air travel.
- Suitability for the return flight (in the case of a round trip itinerary)
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Section asking whether it is a contagious disease.
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- Is it an infectious disease?
- If the answer is "yes", please fill in the details (possibility of infecting others, preventive measures, etc.) (Entry example: While five days have not passed since the onset of symptoms, there is no germ discharge, and the diagnosis is that the infection of others can be prevented by wearing a mask.
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Section asking about the impact on other customers.
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- For the condition and state of health of the customer (patient), will it harm other customers? Or is there a possibility of harm?
- If the answer is "yes", please fill in the details
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Section asking whether they can remain in a sitting position.
If the answer is "no" and a stretcher needs to be arranged, please confirm customers who will use a stretcher (cot).
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- At the time of takeoff and landing, or when the seatbelt sign is on, can they sit in the seat with the backrest up?
- If the answer is "no", does a stretcher need to be arranged?
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Section asking whether they can do things for themselves.
If the answer is "no", someone needs to accompany them.
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- Can the customer (patient) do things for themselves? (Meals, using the restroom and communicating with the cabin crew, etc.)
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Section asking whether someone needs to accompany them.
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- If someone needs to accompany them, is the coordination enough?
- Can the customer (patient) board the airplane on their own?
- If the answer is "no", what kind of assistance is needed?
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Do they need to inhale oxygen while onboard?
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- Do they need to inhale oxygen while onboard?
- If the answer is "yes", please inform us of the oxygen amount (ℓ / min)
- Do they always use it?
- Is it possible for the customer (patient) or the person accompanying them to operate the oxygen bottle?
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Will they use medical device at the airport or in the aircraft cabin?
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- Do medical procedures using medicine and such need to be done at the airport or in the aircraft cabin? Do they also use medical device? (Example: Artificial respirator, aspirator, etc.)
- If the answer is "yes", please fill in the details of the medical device.
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At the time of a connecting flight, or at arrival, do they need to be hospitalized?
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- At the time of a connecting flight, or after arrival, do they need to be hospitalized?
- If the answer is "yes", please fill in the details of the arrangements.
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Please put the date the medical certificate is issued with the signature of the doctor in charge.
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- Day, month and year it is issued
- Name of the medical institution
- Name of the doctor (signature)
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