If you need special assistance, please fill out this form
Name
First Name
Last Name
1. Name of diagnosis/ surgery/ injury
2. Describe the current health condition / illness of the customer.
3. When was the customer diagnosed with this illness?
-
Month
-
Day
Year
Date
4. Did the customer undergo any surgery? If yes, please provide the surgery date.
No
Yes
Date
-
Month
-
Day
Year
Date
5. Age of the customer.
6. Is the customer currently on any medication? If yes, advise name of medication.
No
Yes
7. Is the customer being accompanied by a companion or is he/she travelling alone?
accompanied
travelling alone
8. Is the customer able to walk, take care of his own needs without assistance?
Yes
No
9. Can the customer sit upright in normal aircraft seat, unassisted, while take-off and landing?
Yes
No
10. Does the customer require a Wheelchair? (if yes, please specify type – WCHR/S/C)
Yes
No
Answer question 11 if you answered YES to question 10.
Wheelchair Assistance SSR CodesThe following SSR codes relate specifically to assistance offered to passengers with reduced mobility. These codes are used by the majority of airlines, but some foreign carriers may utilize a different format. SSR Code Description of Assistance
Please select the type of wheelchair
WCHR Wheelchair assistance required; passenger can walk short distance up or down stairs.
WCHS Wheelchair assistance required; passenger can walk short distance, but not up or down stairs.
WCHC Wheelchair required; passenger cannot walk any distance and will require the aisle chair to board.
WCOB On-board aisle wheelchair requested (for use during flight).
WCMP Passenger is traveling with a manual wheelchair.
WCBD Passenger is traveling with a dry cell battery-powered wheelchair.
WCBW Passenger is traveling with a wet cell battery-powered wheelchair.
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