Fill out a Special Assistance form

Booking Reference *

Lead Passenger *

Passenger(s) requiring assistance *

Airline *

Departure Date *

Type of disability - Please specify exact nature of medical ailment, giving as much information as possible *

Which Service is required? *

WCHR - assistance from check in to boarding gate

WCHS - assistance from check in to boarding gate & ambulift onto plane

WCHC - assistance from check in to boarding gate, lifts & totally immobile

No assistance required (non visible disabilities)

Please give more information on the non visible disability

Wheelchair required? *

Yes

Taking own wheelchair? *

Yes

Make & model of Wheelchair *

Is the wheelchair manually or battery operated? *

Manual

Battery

Type of battery of wheelchair?

Dry cell

Wet cell

Gel cell

Lithium

Please provide wattage of wheelchair battery

Is wheelchair collapsible? *

Yes

Weight of wheelchair *

Open width of wheelchair *

Open height of wheelchair *

Open depth of wheelchair *

Closed width of wheelchair *

Closed height of wheelchair *

Closed depth of wheelchair *

Taking own mobility scooter? *

Yes

Make & model of mobility scooter

Is the mobility scooter manually or battery operated?

Manual

Battery

Type of battery of mobility scooter?

Dry Cell

Wet Cell

Gel Cell

Lithium

Please provide wattage of the scooter battery

Weight of mobility scooter *

Open width of mobility scooter *

Open height of mobility scooter *

Open depth of mobility scooter *

Closed width of mobility scooter *

Closed height of mobility scooter *

Closed depth of mobility scooter *

Does it have removeable handlebars/ seat/ headrest/wheels *

Yes

Do you require extra Medical baggage?

Yes

Approx how many kilos?

Items of medical baggage

Nature of condition. Please provide as much information as possible

Are you taking a CPAP machine? *

Yes

Make & model of the CPAP machine *

Height of CPAP machine *

Width of CPAP machine *

Depth of CPAP machine *

Weight of CPAP machine *

Will the CPAP machine be required on board the plane? *

Yes

Is the CPAP machine battery or mains operated? *

Battery

Mains operated

What type of battery?

Can the battery be removed?

Yes

Can passenger(s) walk unaided? *

Yes

Can passenger(s) bend knees & sit in a seat? *

Yes

Is the passenger(s) taking any medication with them on board? If YES please provide details (must be carried with a supported doctors letter or repeat prescription). If NO then simply enter NA in the box *

Will the medication be needed during the flight? *

Yes

If travelling alone is the passenger able to look after their own on board needs? If NO please provide details. If YES then simply enter NA in the box

Have you been hospitalised or had surgery within 14 days of travel?

Yes

Please provide more information

Does the passenger(s) suffer from asthma/breathing difficulties?

Yes

Any requirements for extra Oxygen (subject to airline conditions and availability)

Yes

Do you have any condition that affects any major organs?

Yes

If yes, please provide more information

Are you undergoing any cancer treatment including chemotherapy or radiotherapy?

Yes

Please provide more information (eg what type, how long in remission)

If transfers have been booked with us, are the passenger(s) able to climb the coach steps? *

Yes

If NO, please provide details. If YES then simply enter NA in the box *

Is the accommodation suitable for the passenger(s) who require assistance? If NO please provide details. If YES then simply enter NA in the box *Please note, it is your responsibility to make sure the accommodation booked is suitable for your needs. Room requests are not guaranteed. *

Contact name *

Contact number *

Email address *

Preferred method of contact *

e-mail

phone