FORM OF INDEMNITY

To be Completed M E D I F Standard Medical Information Form for Air Travel

by Sales Office /
Answer all questions. Put a cross (x) in "YES" or "NO" boxes
Agent Use Block Letters while Completing this Form

Name/Initials/Title :
A
Tel No. Departure City :

B Proposed Flights Details

Medical No
C Nature of Disability Clearance
Required YES

Is Stretcher required On-board

D YES
( If all Stretcher cases must be escorted ) NO NA (In case of ATR 72-500)

Intended Escort ( Name, Sex, Age ,Professional qualification, Segments if

E different from guest) - if untrained state "Travel Companion "

NO
F Wheelchair Required?
YES WCHS WCHC

NO
G Ambulance Arranged Hospital Details
YES

NO
H Other Ground Arrangements Required
YES

Arrangements for delivery at

1 NO YES
airport of departure

Arrangements for assistance

2 NO YES
at Connecting points

Arrangements for meeting

3 NO YES
at airport of Arrival

Other requirements or
4 NO YES
relevant information
Special In-Flight
Arrangements needed such If yes, Describe and indicate for each item: (a) Segment(s) on which required (b) Airline
NO arranged or arranging third party and (c ) at whose expense- Provision of special
as: Special Meals, Special
Equipment such as oxygen etc.. Always requires completion of Part 2 overleaf
Seating, leg Seat, extra YES
I seat(s),special equipment
etc.
Form No: FB/AO-CS/MEDIF/0002, Rev 00, 06th
April 2020 Page 01 of 02
 I hereby relieve the physician whom I shall choose to make a statement on my condition of health of
his/her professional discretion to the extent that he/she be permitted to disclose to the airline's medical
department such details on the condition of my health as may be required by them to judge upon my
medical fitness to travel by air. Such physician's fees shall be met by me, and such medical department's
judgements shall be accepted by me as final. If I am accepted for transportation, the undersigned hereby
release and will indemnify the airline its representatives and agents from all claims for compensation or
damaged sustained in connection with the deterioration of my illness as a result of l being accepted for
transportation by air. In case of legal dispute, the undersigned will have to prove that any such damage
sustained has not been caused wholly or in part by my physical, mental or medical condition. The
undersigned further agrees to pay all additional costs, and will be responsible for all damages and expenses
incurred by the airline or third parties through this transportation. The undersigned also agrees and
undertakes that the airline is not obliged in any way to accept me for my subsequent or return journey
Guests Declaration based on this declaration and the airline's Conditions of Carriage will apply separately to each such journey.
(where needed, to be read by/to the guest,
dated and signed by him/her or his/her behalf
) Place : To be read by/to guest, dated & signed by him or his behalf.

Place: Date:

For Any Queries/Clarifications Contact:

flybig Medical Department

Form No: FB/AO-CS/MEDIF/0002, Rev 00, 06th April20 Page 02 of 02