Medical Travel Clearance and Fitness to Fly Form Template

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Free medical travel clearance and fitness to fly form template for airlines, cruises, medical transport, post-surgical travel, and travel accommodations. Copy, customize, and download instantly.

A medical travel clearance form helps healthcare providers evaluate whether a patient is medically fit for air, cruise, rail, or long-distance travel while documenting any required accommodations, restrictions, or safety considerations. This professionally structured template is designed to support airline MEDIF submissions, post-surgical travel clearance, disability accommodations, oxygen requirements, mobility assistance, and medical liability documentation.

When To Use

Use this template when a patient requires physician clearance for commercial air travel, cruise travel, medical transportation, post-hospital discharge transportation, international travel, mobility accommodations, or fitness-to-fly certification.

Template

MEDICAL TRAVEL CLEARANCE AND FITNESS TO FLY FORM

1. PATIENT INFORMATION

Patient Full Name: [First Name Last Name]
Date of Birth: [MM/DD/YYYY]
Gender: [M / F / Other]
Address: [Street Address]
City, State, ZIP: [Location]
Phone Number: [Phone]
Email Address: [Email]
Medical Record Number (MRN): [Number]

2. TRAVEL AND ITINERARY DETAILS

Booking or Reservation Reference: [Reference Number]
Airline / Cruise Line / Transport Provider: [Carrier Name]
Flight or Transport Number: [Number]
Date of Departure: [MM/DD/YYYY]
Departure City: [City]
Destination City: [City]
Return Travel Date (if applicable): [MM/DD/YYYY]

Additional Travel Segments:
[Insert additional flights, layovers, cruises, or transfers]

3. TREATING PHYSICIAN ASSESSMENT
(To be completed by a licensed medical professional)

Primary Diagnosis or Reason for Travel:
[Diagnosis / Procedure / Medical Reason]

Date of Diagnosis, Hospitalization, or Surgery:
[MM/DD/YYYY]

Recent Symptoms or Complications:
[Describe symptoms, limitations, or recent clinical concerns]

Current Medical Stability:

[ ] Stable for travel
[ ] Stable with accommodations
[ ] Requires further evaluation before travel
[ ] Not medically fit for travel at this time

FITNESS FOR TRAVEL DETERMINATION

[ ] The patient is medically fit to travel without assistance.

[ ] The patient is medically fit to travel with the following accommodations:

- Wheelchair assistance
- Airport escort assistance
- Supplemental oxygen
- Stretcher transport
- Extra legroom seating
- Limited walking requirements
- Frequent movement during travel
- Compression stockings
- Dietary accommodations
- Assistance with medications
- Other accommodations: [Specify]

[ ] The patient is not medically fit for travel at this time.

4. MOBILITY AND FUNCTIONAL STATUS

Can the patient walk independently?
[ ] Yes
[ ] No

Wheelchair Assistance Required:

[ ] No wheelchair assistance needed
[ ] WCHR – Passenger can climb stairs but requires wheelchair assistance through terminal
[ ] WCHS – Passenger cannot climb stairs and requires assistance to aircraft seat
[ ] WCHC – Passenger is completely immobile and requires full assistance

Can the patient tolerate prolonged sitting?
[ ] Yes
[ ] No

Is a medically trained escort recommended?
[ ] Yes
[ ] No

Escort Name (if applicable): [Name]
Escort Qualifications (if applicable): [Credentials]

5. OXYGEN AND MEDICAL EQUIPMENT REQUIREMENTS

Is supplemental oxygen required during travel?
[ ] Yes
[ ] No

If yes:

Required Flow Rate:
[ ] 2L/min
[ ] 4L/min
[ ] Other: [Specify]

Oxygen Use:
[ ] Continuous
[ ] Intermittent

Additional Medical Equipment Required:

- CPAP/BiPAP
- Portable oxygen concentrator
- Humidicrib
- Stretcher
- Mobility device
- Medication refrigeration
- Other: [Specify]

6. MEDICATIONS AND MEDICAL RESTRICTIONS

Current Medications:
[Medication List]

Special Dietary Restrictions:
[Restrictions]

Does the patient have a history of deep vein thrombosis (DVT)?
[ ] Yes
[ ] No

Recommended DVT Prevention Measures:

- Frequent ambulation
- Compression stockings
- Hydration
- Medication prophylaxis
- Other: [Specify]

Is the patient contagious or subject to public health restrictions?
[ ] Yes
[ ] No

If yes, explain:
[Details]

7. EMERGENCY CONTACT INFORMATION

Emergency Contact Name: [Name]
Relationship to Patient: [Relationship]
Phone Number: [Phone]
Destination Address or Hotel:
[Location]

8. PHYSICIAN CERTIFICATION

I certify that I have evaluated the patient named above and that the information contained in this form is accurate to the best of my knowledge.

Based on my clinical assessment, the patient:

[ ] Is medically fit for the proposed travel itinerary
[ ] Is medically fit with accommodations listed above
[ ] Is not medically fit for travel at this time

I further certify that:

- The patient does not appear to have a contagious condition that would create unreasonable public health risk during travel
- Appropriate travel precautions and accommodations have been reviewed with the patient
- Recommendations provided are based on current medical evaluation

Physician Name: [Full Name]
Credentials: [MD / DO / NP / PA]
Medical License Number: [License Number]
Hospital / Clinic Name: [Facility Name]
Phone Number: [Phone]
Fax Number: [Fax]
Email Address: [Email]

Physician Signature: ___________________________
Date: _______________________________________

9. PATIENT CONSENT AND RELEASE

I authorize my treating physician and medical team to disclose relevant medical information to the transportation provider for purposes of evaluating my fitness for travel and determining necessary accommodations.

I acknowledge that travel may pose risks related to my medical condition, including worsening symptoms, complications, delayed access to medical care, blood clot risk, oxygen needs, or mobility limitations.

I understand that transportation providers may require additional documentation or deny travel clearance based on medical review.

Patient / Guardian Signature: ___________________________
Date: ________________________________________________

10. IMPORTANT NOTICE

Many commercial airlines and cruise providers require submission of their own proprietary Passenger Medical Information Form (MEDIF) or accessibility forms in addition to physician clearance.

Patients are encouraged to contact the carrier directly regarding:

- Advance medical review requirements
- Oxygen policies
- Mobility assistance
- Battery-powered medical device approval
- Wheelchair accommodations
- Stretcher transport approval
- International quarantine or infectious disease policies

Some carriers require submission of medical forms at least 48–72 hours before departure.

Example

MEDICAL TRAVEL CLEARANCE AND FITNESS TO FLY FORM

1. PATIENT INFORMATION

Patient Full Name: Taylor Morgan
Date of Birth: 04/18/1995
Phone Number: (555) 555-2144

2. TRAVEL AND ITINERARY DETAILS

Airline: Horizon Airways
Flight Number: HA402
Departure Date: 06/10/2027
Departure City: Miami, FL
Destination City: Denver, CO

3. TREATING PHYSICIAN ASSESSMENT

Primary Diagnosis:
Status post uncomplicated knee surgery.

Current Medical Stability:
Stable for travel with accommodations.

FITNESS FOR TRAVEL DETERMINATION

[X] Patient is medically fit to travel with accommodations.

Required Accommodations:
- Wheelchair assistance through airport
- Extra legroom seating
- Frequent ambulation during flight
- Compression stockings

4. MOBILITY STATUS

[X] WCHR – Passenger requires wheelchair assistance through terminal but can board aircraft.

6. MEDICATIONS AND MEDICAL RESTRICTIONS

Current Medications:
Pain medication as prescribed.

History of DVT:
No.

7. PHYSICIAN CERTIFICATION

Physician Name: Dr. Emily Carter, MD
Hospital: Evergreen Orthopedic Associates
Phone: (555) 555-3001

Physician Signature: ___________________________
Date: 06/01/2027

Frequently Asked Questions

What is a medical travel clearance form?

A medical travel clearance form is a document completed by a healthcare provider to evaluate whether a patient is medically fit for travel and whether accommodations are required.

What is a MEDIF form?

A MEDIF, or Medical Information Form, is a travel medical clearance document commonly required by airlines for passengers with significant medical conditions or special assistance needs.

When do airlines require medical clearance?

Medical clearance may be required after recent surgery, hospitalization, oxygen dependence, significant mobility limitations, contagious illness concerns, or medical instability.

What do wheelchair assistance codes like WCHR and WCHS mean?

These are airline mobility assistance codes indicating different levels of mobility and boarding assistance needs.

Why are oxygen and DVT risk documented on travel clearance forms?

Long-distance travel and reduced cabin oxygen pressure can worsen certain medical conditions or increase blood clot risk in vulnerable patients.

Medical Travel Clearance and Fitness to Fly Form Template

When To Use

Template

Example

Frequently Asked Questions

What is a medical travel clearance form?

What is a MEDIF form?

When do airlines require medical clearance?

What do wheelchair assistance codes like WCHR and WCHS mean?

Why are oxygen and DVT risk documented on travel clearance forms?

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