Print this page and fax or post to Flights Direct
Fax 07 886 6256
PO Box 593, Tokoroa, New Zealand

You will need to fill out a Medical Certificate for every person with a pre-existing Medical Condition

PART A: TO BE COMPLETED BY THE APPLICANT

Name __________________________________________________________________

Weight _______________ Height ______________________ Age ______________

Countries to be visited _______________________________________________

_______________________________________________________________________

Main Destination ______________________________________________________

Departure Date ______________________ Return Date _____________________

Have you booked this journey with this agency ?       YES / NO

Have you been refused travel insurance or had 
 any terms imposed for this journey ?                 YES / NO

Have you made any medical travel insurance claim
 within the last three years ?                        YES /NO 

If, YES, to any of these questions please supply details: _____________

_______________________________________________________________________

I consent to the information supplied on this Medical Certificate being
released to the insurer or its agent and for them to contact my doctor
for further medical information for the purpose of this insurance or 
for any subsequent claim that may occur.

Applicant's signature: __________________________________________________

PART B: TO BE COMPLETED BY THE APPLICANT'S DOCTOR

Doctor's Phone _____________________ Doctor's Signature _________________

Is the patient fit to undertake the proposed
 journey without adverse effects ?                           YES / NO

Do you anticipate the patient requiring medical attention ?  YES / NO

1. HEART CONDITION ?

Date diagnosed __________________ Type __________________________________

Medication/Surgery ______________________________________________________

_________________________________________________________________________

Angina on exertion ?     YES / NO

Angina on rest ?         YES / NO

Hypertension ?           YES / NO

Last three blood pressure readings (Reading and date) 

1)_________________________________  2)_________________________________ 

3)_________________________________

2. CANCER ?

Date diagnosed ________________ Type____________________________________

Condition is controlled ? YES / NO              Metastatic ? YES / NO

Medication/Surgery _____________________________________________________

________________________________________________________________________

3. CIRCULATORY ?

Date diagnosed ________________ Type____________________________________

Condition is controlled ? YES / NO

Medication/Surgery _____________________________________________________

________________________________________________________________________

Other related condition ? (Details) ____________________________________

________________________________________________________________________

4. RESPIRATORY CONDITION ?

Date diagnosed ________________ Type____________________________________

Condition is controlled ? YES / NO 

Medication/Surgery _____________________________________________________

________________________________________________________________________

Last three peak flow readings (Reading and date) 

1)_________________________________  2)_________________________________ 

3)_________________________________

5. HOSPITALISATION (IN LAST SIX MONTHS) ?

Date hospitalised __________________  Details __________________________

________________________________________________________________________

6. TERMINAL CONDITION ? 

YES / NO       Details _________________________________________________

________________________________________________________________________

7. MEDICAL CONDITIONS CURRENTLY UNDERGOING INVESTIGATION ?

YES / NO       Details _________________________________________________

________________________________________________________________________

8. OTHER CONDITIONS AND/OR MEDICATIONS TAKEN ?

YES / NO       Details _________________________________________________

________________________________________________________________________

________________________________________________________________________