Pilot License Medical Clearance Form
Use this form to submit the information needed for a pilot medical clearance review or appointment request.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Communication Method
*
Please Select
Email
Phone Call
Text Message
Medical Clearance Details
Purpose of Clearance Request
*
Please Select
Initial pilot medical clearance
Renewal of existing medical clearance
Upgrade to a higher medical certificate class
Return to flying after medical leave
Clearance after a medical event
Other
Current Aviation Medical Certificate Class or Type
Please Select
Class 1
Class 2
Class 3
Basic Medical Certificate
Other type
Not applicable
Existing Medical Restrictions or Special Considerations for Flying
Request Type
*
New clearance
Renewal
Appointment and Submission Details
Preferred Appointment
*
Submit
Should be Empty: