Nature of Illness
Template Letters | Permission to Fly with Oxygen
This letter is intended to allow patients to fly with oxygen. It is intended to be sent by a medical professional on behalf of the patient. The patient should keep an original signed copy for their records. Please replace all [bolded] words with the appropriate language.
[PRINT ON MEDICAL CENTER OR INSTITUTION LETTERHEAD]
Nature of Illness: __________________________________________________
Liters per minute required assuming a cabin altitude of 8,000 ft: ____
Continuous or Pulse dose: ______________
Make and model of Portable Oxygen Concentrator (POC): [CHECK ONE]
( Inogen One
( SeQual Eclipse
( Respironics EverGo
( Delphi RS-00400 (EVO Central Air)
( Invacare XPO2
( AirSep Lifestyle
( AirSep Freestyle
I, [NAME], (MD, DO) licensed to practice medicine in the state of [STATE], certify that [PATIENT’S NAME] is a patient under my care. It is my professional judgment that he/she is physically able to complete an airline flight safely without requiring extraordinary medical assistance, even if the flight is of greater length than scheduled, terminates at a point other than the expected destination, or involves other irregular operations.
I further certify that the above-mentioned patient does not have a disease or infection that can be transmissible to other persons during the normal course of the flight.
[YOUR NAME], [DATE]
[SIGNATURE]
[Print Name]
[Address]
[Phone NUMBER] [Fax NUMBER]
................
................
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