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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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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 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 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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Do you use medical equipment onboard?
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- Is it necessary to use medical equipment or perform medical procedures using drugs, etc. inflight?
(e.g. ventilator, aspirator, oxygen concentrator, etc.)
- If "Yes", please provide the product name, manufacturer, model number, and type and number of batteries.
The following batteries are classified as hazardous materials. Lithium-ion battery: Watt rating (wh) Lithium battery: Lithium content (g) Lead acid battery: watt rating (wh)
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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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Are there any other special meals, in-flight services, etc. that we should be aware of?
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- If "Yes", please indicate any points to be noted.
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Please describe your (the patient's) current condition.
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- Please provide a detailed description including examination findings and treatment status.
- Please provide the expiration date, if any, as specified by the physician.
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(12) Institution issuing Medical Information Form (MEDIF)
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Please provide the name of the medical institution, the name of the physician, and the date of Medical Information Form (MEDIF).
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- Your name (self-addressed) (Example: Ichiro Suzuki)
- Name of medical institution/specialty (Example: Tennozu Hospital)
- Telephone number (medical institution) (Example: 03-5460-xxxx)
- Emergency Contact
- Date of issue
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