EYCM WebPage MEDA Doctor Request · Customer Self-Service

Guest Details

Name

Etihad Booking Reference

Age (in years)*

Age (in months)*

Sex*

Weight (in Kgs)*

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Declaration of illness, accident and/or treatment

Diagnosis of Onset

Diagnosis*

Date*

Surgery*

Yes

Surgery Details*

Nature of Surgery*

Date*

Prognosis for a Safe Trip *

Good

Guarded (Medical escort mandatory)

Poor (Medical escort mandatory)

Contagious and communicable disease *

Yes

Contagious and communicable disease details *

Intellectual disability *

Yes

Description *

Vital signs

Temperature (Celsius)*

Pulse*

RR*

BP*

Oxygen Saturation % (on room air)*

Hemoglobin (G/Dl)*

Supplementary Oxygen (on ground litre/min)*

Oxygen Saturation (on supplemental oxygen %) *

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Doctor's first name:

Doctor's last name:

Doctor's email:

Hospital name:

Telephone:

Please compile all medical reports and other supporting documents into one pdf file and upload.*

Yes

Signature

Doctor's declaration for medical clearance

Declaration of illness, accident and/or treatment

Summary

Thank you!

Your details have been submitted successfully.

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MEDA Doctor Login

Doctor's declaration for medical clearance

Declaration of illness, accident and/or treatment

Summary

Thank you!

Your details have been submitted successfully.

Error!

Data is not available. You cannot proceed with the form submission.

Error!

This form is already submitted. You cannot re-submit the form.