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PHYSICIAN S CONSENT FORM For use of Portable Oxygen Concentrator POC Must be completed and signed by the passenger and passenger s physician Additional information can be found at www. aa*com Physician s Name Address Telephone Fax Customer Information This document is to remain in your personal possession and must be presented to an airline representative upon request. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. and ground connection time where the POC is planned to be used per manufacturer s recommendation for unanticipated delays. Electrical power ports may be available on certain flight but cannot be depended upon to power the device. They are not a substitute for fully charged batteries. I understand and agree with the above information Passenger s Signature Physician Information The following information relates to care. Date who is a patient in my Passenger/Patient name He/She needs to operate a POC device at a flow rate of Liters per minutes LPM corresponding to the pressures of the aircraft under normal operating conditions. Cabins are pressurized to an altitude of 8 000 feet. Make and model of POC FAA Approved Models AirSep LifeStyle RTCA sticker required AirSep FreeStyle AirSep FreeStyle 5 AirSep FOCUS DeVilbiss iGo Inogen One Inogen G2 Inogen One G3 International Biophysics Lifechoice by Inova Labs Inova Labs Lifechoice Activox Invacare Corporation s SOLO2 XPO2 XPO100 XPO100B Oxlife Independence Oxus RS-00400 Precision Medical Easy Pulse PM4150 Phillips/Respironics-SimplyGO Respironics-EverGo SeQual Eclipse Model 1000 SeQual Eclipse 2 Model 1000A and SeQual Eclipse 3 Model 1000B SAROS Model 3000. Patient is able to operate the POC and recognize and respond appropriately to its alarms. Yes or No If the answer is no American Airlines will require the Passenger/Patient to travel with a companion able to perform these functions. Patient will require the use of the device during circle all that apply Physician s Signature Taxi Take-off In-flight Landing. aa*com Physician s Name Address Telephone Fax Customer Information This document is to remain in your personal possession and must be presented to an airline representative upon request. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. Any changes in oxygen requirements such as a revised flow rate will require an updated statement. You are responsible for knowing how to operate your portable oxygen concentrator POC device ensuring that your device is in good condition and free from damage or excessive wear and tear. and ground connection time where the POC is planned to be used per manufacturer s recommendation for unanticipated delays. .

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