Airline Medical Oxygen Request Form
Use this form to request in-flight medical oxygen assistance and share the details needed for airline review and coordination.
Passenger and Flight Details
Passenger Full Name
*
First Name
Last Name
Airline Name or Flight Number
*
Departure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Departure Airport
*
Arrival Airport
*
Seat Number (if available)
Medical Oxygen Request Details
Does the passenger require medical oxygen during the flight?
*
Yes
No
Oxygen flow rate or device requirements
Duration or timing of oxygen use during the flight
Medical Clearance and Emergency Contact
Physician Clearance or Medical Approval Document
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Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies or Medical Conditions Relevant to Oxygen Use
Acknowledgment of Crew Instructions for Oxygen Use
*
I will follow all airline crew instructions regarding oxygen use
Submit Request
Should be Empty: