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FITNESS FOR AIR TRAVELMEDICAL DEPARTMENTMONDAY TO FRIDAY:SATURDAY TO SUNDAY:EMAIL:6 a.m. – 8 p.m. ET6 a.m. – 6 p.m. 9-7039(Toll-free from North America)(Long distance charges apply)FAX:1-888-334-77171-514-828-0027(Toll-free from North America)(Long distance charges apply)The personal and medical details you provide on this form will be used by Air Canada to handle your request formedical approval and to arrange the necessary assistance for your travel arrangements on Air Canada operatedflight(s). Your medical details will not be disclosed to other airlines.In compliance with Accessible Transportation for Persons with Disabilities Regulations, Air Canada can retain anelectronic copy of your personal health information for at least three (3) years for the purpose of permitting Air Canadato use that information if you make another request for a service.Do you agree?YesNoIf yes, please note Air Canada may require updated documents depending on your medical condition. You shouldread Air Canada’s privacy policy for further information and for the contact details of the privacy office.I hereby consent to my personal and/or medical data being processed, used for the purposes set out above.PASSENGER/LEGAL GUARDIAN SIGNATUREPLACEDATEThere are 5 sections to this form. Please ensure that the sections relevant to your request are properly filled out byyour physician.The sections are:PATIENT’S MEDICAL INFORMATION . 2 - 3SECTION 1 – TRAVELLING WITH OXYGEN . 4SECTION 2 – DECLARATION OF ILLNESS, ACCIDENT OR TREATMENT . 5 - 7SECTION 3 – EXTRA SEATING BY REASON OF OBESITY 8SECTION 4 – TRAVELLING BETWEEN CANADA AND THE U.S.A 9ACF5002-1-UA (2020-06)

PASSENGER INFORMATIONFIRST NAMEFAMILY NAMEBOOKING REFERENCEDATE OF BIRTHTELEPHONEEMAILFLIGHT NUMBERDATEFROMTOFLIGHT NUMBERDATEFROMTOFLIGHT NUMBERDATEFROMTOPlease note: The following sections need to be filled out by your physician. You can either save and send theform electronically or print it to be filled out by hand. Duly completed forms must be emailed toacmedical@aircanada.caPHYSICIAN INFORMATIONATTENDING PHYSICIAN NAMECOUNTRY OR PROVINCE OF REGISTRATIONLICENCE NUMBERTELEPHONEFAXEMAILPHYSICIAN SIGNATUREDATE2

PASSENGER NAMEBOOKING REFERENCEPATIENT’S MEDICAL INFORMATION(MANDATORY FOR ALL FLIGHTS NOT SUBJECT TO SECTION 4 / USA FLIGHTS)DIAGNOSISDATE OF ONSETIs the condition resolved/stable?YesNoCurrent symptoms and severity:Nature and date of any treatment/surgery:Date:ADDITIONAL MEDICAL INFORMATION – ALL QUESTIONS MUST BE ANSWEREDAnemia:NoYes – if yes, indicate hemoglobin:Requires supplemental oxygen for travel:NoYes – if yes, please complete Section 1Requires attendant or assistance with mobility:NoYes – if yes, please complete Section 2aRespiratory condition (acute or chronic):NoYes – if yes, please complete Section 2bSeizure disorder:NoYes – if yes, please complete Section 2cCardiac condition (including syncope):NoYes – if yes, please complete Section 2dPsychiatric/Behavioural/Cognitive Condition:NoYes – if yes, please complete Section 2eAllergy to cats or dogs:NoYes – if yes, please complete Section 2fRequires exemption from wearing face covering:NoYes – if yes, please complete Section 2b eVital signs:Prognosis for a safe trip:PHYSICIAN SIGNATUREOXYGENSATURATIONGood(No problemsAnticipated)%ROOM AIR dLHEARTRATEPoor(Problems likely)DATE3

PASSENGER NAMEBOOKING REFERENCESECTION 1 – TRAVELLING WITH OXYGENOxygen saturation:%Room airL.p.m. continuousO2Personal Oxygen Concentrator (P.O.C.) pulse settings:123456P.O.C. continuous settings:YesDoes the patient already use oxygen on the ground?1 L.p.m.2 L.p.m.3 L.p.m.NoIf yes, please provide the following information:O2 tankFlow rate:P.O.C.Brand:L.p.m.Pulse delivery at settings:Hours per day1Continuous flow delivery at:or231 L.p.m.4562 L.p.m.Hours per day3 L.p.m.Hours per dayCHOOSE ONE OF THE FOLLOWING OPTIONS FOR FLIGHTOPTION 1Oxygen Request* (provided by Air Canada – fees applicable / Nasal prongs only, no mask)Oxygen cylinder – required flow:2 L.p.m.3 L.p.m.4 L.p.m.5 L.p.m.more than 5 requiredIs a pediatric mask required?OPTION 2P.O.C.** (passenger provided)orYesNoBrand:Pulse delivery at setting:1Continuous flow delivery at:1 L.p.m.23452 L.p.m.63 L.p.m.Is the passenger familiar with their P.O.C. and capable of managing the device on theirown, including responding to alerts and changing of batteries?YesNoDoes the passenger have sufficient batteries for their trip? (Aircraft do not have electricaloutlets able to support power to a P.O.C.)YesNoADVANCE NOTICE REQUIRED(Best efforts will be made to accommodate requests made within this timeframe).***North America:48 hoursInternational:72 hoursP.O.C. or C.P.A.P.:48 hoursPHYSICIAN SIGNATUREDATE4

PASSENGER NAMEBOOKING REFERENCESECTION 2 – DECLARATION OF ILLNESS, ACCIDENT OR TREATMENTDIAGNOSISDATE OF ONSETTreatment:Medications:Will a cabin pressure the equivalent to an elevation of 2,400 m (8,000 ft) above sea level (i.e.,a 25% reduction in the ambient partial pressure of oxygen and an expansion of the volume ofgas) affect the passenger’s medical condition?a)Does the patient require an attendant to travel?YesYesNoNoMedical reason passenger is unable to travel alone:Is an escort required in flight to assist with eating, medications and toileting?Who should accompany passenger?YesNoDoctorNurseOther (adult family/friend able to attend to all personaland safety needs)Bowel Control:YesNoIf no, mode of control:Bladder Control:YesNoIf no, mode of control:Able to walk without assistance?YesNoIf no, please provide the following information:Wheelchair required for boardingTo aircraftTo seatPassenger has own wheelchairElectricalManualFor adults with cognitive disabilities not needing an attendant, is airportYesNoassistance required?PHYSICIAN SIGNATUREDATE5

PASSENGER NAMEBOOKING REFERENCESECTION 2 – DECLARATION OF ILLNESS, ACCIDENT OR TREATMENT- CONTINUEDb)Chronic Pulmonary ConditionYesNoIf yes, please provide the diagnosis:YesShort of breath:NoIf yes, please provide the following information:On exertionAt restCan the passenger tolerate mild exertion-example, walk 100 metres at a normal pace orclimb 10-12 stairs-without symptoms?YesNoHas the passenger recently taken a commercial aircraft in these same conditions?YesNoYesNoIf yes, any medical problems or complications?YesHas the passenger had recent arterial gases?NoIf yes, what were the results?pCO2pO2SaturationBlood gases were taken on:c)Seizure?YesRoom air%Date of exam:L.p.m.OxygenNoCause/Type:When was the last seizure?Last hospital visit for seizure:YesAre the seizures controlled by medication?d)Cardiac conditions?YesNoNoCan the passenger tolerate mild exertion—example, walk 100 metres at a normal pace orclimb 10-12 stairs—without symptoms?Angina:YesNo Date of last episode:Limit to physical activity:NoneMyocardial infarction:YesSlightMarkedSevereNo Date:Complications:YesNoSpecify:Low risk on angiography or non-invasive studies?YesNoIf angioplasty or coronary bypass, date:PHYSICIAN SIGNATUREDATE6

PASSENGER NAMEBOOKING REFERENCESECTION 2 – DECLARATION OF ILLNESS, ACCIDENT OR TREATMENT- CONTINUEDd)Cardiac Failure:YesNo Date of last episode:Functional class:No symptomsShort of breath:With major effortWith light effortAt restYesSyncope:No Diagnosis/Presumed cause:Investigations, if any:e)Psychiatric/Behavioural/Cognitive Condition?YesNoDiagnosis:Is there a possibility that the passenger will become agitated during the flight, causing safetyrisk or significant distress to others?YesNoHas he/she previously flown in a commercial aircraft in this condition?YesNoIf yes, did he/she travel:AloneAccompanied - Date of travel:f)Allergy?YesNoDoes the passenger carry an asthma inhaler/pump?Allergy to cats:YesYesNoNoIf yes, does the passenger suffer from:itchy eyesAllergy to dogs:wheezingYesrunny nosecoughitchy skin/rashdyspnearunny nosecoughitchy skin/rashdyspneaNoIf yes, does the passenger suffer from:itchy eyeswheezingOther medical information:PHYSICIAN SIGNATUREDATE7

PASSENGER NAMEBOOKING REFERENCESECTION 3 – EXTRA SEATING BY REASON OF OBESITYFOR ITINERARIES WHOLLY WITHIN CANADA ONLYTHIS SECTION REQUIRED ONLY IF REQUESTING AN EXTRA SEAT FOR REASONS OF OBESITYThe information provided herein will assist Air Canada in determining passenger’s right to accommodation in the formof extra seating without charge.For first assessment, please ensure all sections above are completed by the attending physician.If this is a renewal, this section can be completed by an occupational therapist, a physiotherapist or nurse practitionerprovided no other co-morbidities had been identified by the physician in the initial assessment and passenger’s fitnessfor flying has not changed in the last 2 years.Measurements (please use metric measurements)a)Weightkgb)Heightcmc)Body Mass Indexd)Surface measurement* A to B(kg/m2)cm*Surfacemeasurement should be calculated by measuring the distancebetween the extreme widest projection points of the patient whenseated as per the following instructions:1.2.3.4.5.6.Have your patient sit on a paper covered examination table.Rest a ruler or straightedge on the left side of patient at the widestpoint (hip or waist) as shown on diagram at right.Mark the touch point between the ruler and the paper as Point A.Rest a ruler or straightedge on the right side of patient at thewidest point (hip or waist).Mark the touch point between the ruler and the paper as Point B.Measure the distance between Point A and Point B, and indicatethis measurement above under “Surface Measurement” (item d).Call the Air Canada Medical Assistance Desk at 1-800-667-4732 and provide your bookingreference in order to request extra seating for medical reasons and make any othernecessary arrangements for your flight.PHYSICIAN SIGNATUREDATE8

PASSENGER NAMEBOOKING REFERENCESECTION 4 – TRAVELLING BETWEEN CANADA AND THE U.S.A.FOR PASSENGERS TRAVELLING ON A FLIGHT BETWEEN CANADA AND THE U.S.A., WE ONLYREQUIRE THE COMPLETION OF THIS SECTION 4 OF THIS FITNESS FOR AIR TRAVEL FORM.WE STRONGLY RECOMMEND THAT SECTION 2 BE COMPLETED BY THE ATTENDINGPHYSICIAN TO ENSURE THAT PASSENGER’S CONDITION WILL NOT BE AGGRAVATED IN AHYPOXIC CABIN ENVIRONMENT.1)Reasonable doubtWill the passenger be able to complete the flight safely without requiring extraordinary medical attention?YesNoIf no, the passenger:a)b)c)d)e)2)Has an unstable medical condition;Has a medical condition that may worsen in a hypoxic environment;May require medical assistance during flight;May require the use of onboard emergency medical equipment; orIs unable to self-administer medications or routine medical care necessary to maintain thestability of his/her condition during a flight (e.g., insulin injection).Communicable diseasesa)Does the passenger have a disease or infection that would under the present conditions becommunicable to other persons and that could pose a direct threat to the health or safety of others duringthe normal course of the flight?Yesb)NoAre there any conditions or precautions that would have to be observed to prevent the transmission ofthe disease or infection to other persons in the normal course of the flight?YesNoIf yes, state which:c)Does the passenger have a bonafide medical condition which would preclude them from wearing a facialcovering or mask?Yes3)NoOxygenDoes the passenger use oxygen on the ground or will the passenger require supplemental oxygen in flight?YesNoIf yes, please complete SECTION 1 (page 3)CLEAR FORM*Must be dated within 10 days of the date of the initial departing flight.PHYSICIAN SIGNATUREDATE*9

FITNESS FOR AIR TRAVEL MEDICAL DEPARTMENT MONDAY TO FRIDAY: 6 a.m. –8 p.m. ET SATURDAY TO SUNDAY: 6 a.m. – 6 p.m. ET . EMAIL: acmedical@aircanada.ca