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Get Physician Consent form for POC

Physician Consent Form for an Individual Who Needs to Use a Portable Oxygen Concentrator POC During a Southwest Airlines Flight Must be completed in full by the Passenger s physician and printed on physician s letterhead Physician s Name Place of Business Address Telephone Fax Please note that in accordance with Special Federal Aviation Regulation SFAR No. 106 14 CFR Part 121 only the AirSep FreeStyle AirSep LifeStyle AirSep Focus AirSep FreeStyle 5 Delphi RS-00400 DeVilbiss Healthcare iGo Inogen One Inogen One G2 Inogen One G3 Inova Labs LifeChoice Inova Labs LifeChoice Activox International Biophysics LifeChoice Invacare XPO2 Invacare SOLO2 Oxlife Independence Oxygen Concentrator Oxus RS-00400 Precision Medical EasyPulse Respironics EverGo Respironics SimplyGo SeQual Eclipse SeQual eQuinox Oxygen System model 4000 SeQual Oxywell Oxygen System model 4000 SeQual Saros and VBOX Trooper Oxygen Concentrator models are approved for use during flight. Compressed or liquid medical oxygen may not be used or transported on Southwest Airlines. The following information relates to who is a patient in my care. He/She Passenger/Patient name is able to operate the POC and recognize and respond appropriately to its alarms. Compressed or liquid medical oxygen may not be used or transported on Southwest Airlines. The following information relates to who is a patient in my care. He/She Passenger/Patient name is able to operate the POC and recognize and respond appropriately to its alarms. Yes No If the answer is no the Passenger/Patient must travel with a companion who is able to perform these functions. initial will require the use of the device during check all that apply taxi takeoff in air and/or landing. will be using a device with a maximum oxygen flow rate of corresponding to the pressure of the aircraft under normal operating conditions. Cabins are pressurized to an altitude of 8 000 feet. physician signature date Form must be dated within one year of travel date. He/She Passenger/Patient name is able to operate the POC and recognize and respond appropriately to its alarms. Yes No If the answer is no the Passenger/Patient must travel with a companion who is able to perform these functions. Yes No If the answer is no the Passenger/Patient must travel with a companion who is able to perform these functions. initial will require the use of the device during check all that apply taxi takeoff in air and/or landing. initial will require the use of the device during check all that apply taxi takeoff in air and/or landing. will be using a device with a maximum oxygen flow rate of corresponding to the pressure of the aircraft under normal operating conditions. will be using a device with a maximum oxygen flow rate of corresponding to the pressure of the aircraft under normal operating conditions. Cabins are pressurized to an altitude of 8 000 feet. physician signature date Form must be dated within one year of travel date. He/She Passenger/Patient name is able to operate the POC and recognize and respond appropriately to its alarms. Yes No If the answer is no the Passenger/Patient must travel with a companion who is able to perform these functions. initial will require the use of the device during check all that apply taxi takeoff in air and/or landing. .

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