Aviation Medicals Consent Form

THE MEDICAL: Administration

I hereby give my informed consent to undergo a CAA/ FAA medical examination with Dr John Pitts/ Vision in Aviation Ltd (“the AME”). I consent to the electronic and written statutory disclosure of the results and outcome of all examination reports to the UK Civil Aviation Authority /the FAA and the transmission of my ECG if necessary to an over-reading cardiologist.


I understand that the AME will try to help me obtain my certification legally by obtaining the required reports and results on the conditions I have declared or which are discovered at the medical, assessing these, and where necessary passing them to the UK CAA or US FAA for assessment.


I confirm that I will fully disclose all my past and current medical history on the relevant electronic and/ or paper forms and in email or spoken discussion with the AME. This will include all conditions since birth, where relevant before birth, and conditions which have been declared at previous medicals.


I understand that failure to be honest and complete in my disclosure of medical issues can lead to enforcement investigations and proceedings, criminal prosecution, and possibly fines and custodial sentences. In particular, I further understand that if a prosecution by the CAA is successful the penalty for providing incomplete, inaccurate or false information to obtain a medical certificate is a criminal offence carrying a maximum penalty of 2 years imprisonment and/or an unlimited fine.


I understand that failure to be honest and complete in my disclosure of medical issues is likely to terminate the AME/ client relationship with Dr John Pitts.


I understand that where the initial medical, or prior renewal or revalidation medicals, were not performed in accordance with the regulatory requirements it will be necessary to comply with these retrospectively and refer the matter to the CAA, and that this will entail extra work and may entail additional costs.


THE MEDICAL: Dress and undress

I understand that the aviation medical assessment involves a physical examination of the major body systems, and that I must dress appropriately and also will have to undress, removing my outer clothing to allow access to and contact with my body for this purpose.


I understand that for both men and women a helpful dress standard is loose, comfortable clothing and that partial undress will be down to underpants for males and underpants and sports bra for females, but that an ECG may have to be performed bare-chested.
I understand that I must carry out breast self-examination before the medical so that the AME can honestly record that there is no breast abnormality.


I understand that a rectal and/or gynaecological examination is not part of the aviation medical and that I will confirm absence of symptoms and/ or up to date screening in these areas so that the AME can honestly record that there is no anal or gynaecological abnormality.


THE MEDICAL: Chaperone

I understand that the AME’s chaperone policy can be found at www.pilotmedical.com.

I understand that a chaperone is available upon request. Having read the policy and reflected on it, and been afforded an opportunity for clarification, I have decided whether or not I wish to have a chaperone present at my medical examination.


THE MEDICAL: Observers.


I understand that Dr John Pitts may train medical students, technicians, nurses and other professions allied to medicine who may therefore be present during the examination with my permission.

I understand that on occasion the medical may need to be observed by CAA auditors.


THE MEDICAL: Mental health assessment

I understand that the medical examination includes a non-specialist assessment of my mental health, and that this includes a mental health questionnaire but is also based on interactions and communications before, during and after the medical examination.

I understand that it is the AME’s duty to report any communications which show
• undue aggression
• lack of comprehension of the medical examination process
• lack of insight into the duty to comply with it, or
• disregard for the duty to comply with the regulatory authority.
• a possible issue with mental health, impulse control or any other human factors hazard


COMMUNICATION

I understand that for audit purposes all communications with and by Dr John Pitts/ Vision in Aviation Ltd (“the AME”) are by email only, not by telephone or messenger apps.


I consent to the transmission of confidential information by regular email by the AME. I confirm that I consent to email communications without extra encryption, in the understanding that email communications are never 100% secure.

I give my permission for the AME to send my reports electronically and/ or in hard copy to the relevant bodies including designated consultant cardiologists for ECG reporting.


I understand that the email trail may be used by the AME and/or CAA for medical assessment (particularly mental health assessment) and audit purposes. I confirm that while the mental health assessment primarily takes place at the medical examination, the AME has a duty to report any concerning communications post medical.

I understand that communication will be with me only, not my relatives or friends or colleagues or flight school or employer or charity or legal representative or any form of personal assistant.

I confirm that I will not turn up un-announced at any address associated with Dr John Pitts or Vision in Aviation Ltd.
I understand that billing depends on time spent and that this increases with the volume of emails. Current billing rates for each email are 1/10 of an hourly rate of £400/ hour.


REPORTS


I will obtain any reports recommended by the AME and send them to the AME myself. I will not depend on my doctors to send the reports or expect my AME to chase the reports. I will where possible try to send all required reports in a single email. I will send these reports in legible multipage PDF scans, not JPGs or any other file type.

I understand that if I refuse to obtain the specialist opinions recommended by the Dr John Pitts/ Vision in Aviation Ltd (“the AME”), then the AME cannot issue my certificate. In such an event my options are an unfit decision so that I can invoke the CAA review and appeal procedure or deferral to the CAA. The AME/ client relationship will cease to exist at this time, and I will need to find another AME to complete the CAA’s instructions.

I understand that all reports must be in English or fully translated into English by an accredited medical translator.
I understand that reports must be on headed paper, be dated, identify me by name and at least one other identifier (Date of Birth or CAA Reference Number), be signed and contain a footer designating the seniority, specialty and GMC reference number of the writer.

I understand that where a consultant report is advised no other grade of doctor’s report will suffice, nor will a GP report suffice; and that when a doctor’s report is advised then no other PAM report will suffice (PAM being ‘profession allied to medicine’ and including nurse, physiotherapist, etc).

I understand that it will sometimes be necessary for me to put in a written GDPR request to my GP for my full subject access GP records (not the patient access version) and to provide these, and I understand that fitness decisions and referrals may not be possible if these are excessively redacted or if pages are missing, or if I have sought alteration of these records by my GP or practice manager before they are provided.


I understand that where blood results or histology reports are required, these shall be submitted as the original laboratory reports, not just comments on these reports by specialists compiling the reports, and that these reports will identify me with at least two identifiers, as above.


I understand that reports must be in multipage PDF (not JPG or screenshots from the NHS app or elsewhere) so that these can be uploaded to Cellma. I understand that where multiple reports are required, these shall be sent in one email when all are available, and that submitting reports piecemeal engages the email charges set out above.


REFERRALS

I understand that if I decide to contact the CAA before the compilation of reports and on-referral process is incomplete, then I will continue to liaise with the CAA thereafter.


I further understand that where I disagree with the AME’s assessment and take the matter to the CAA on my own initiative, this is likely to terminate the AME/ client relationship with Dr John Pitts/ Vision in Aviation Ltd.


Should the case require deferral to the CAA I understand that they may also require additional reports in addition to that already provided and that this may incur additional expense.

I further understand that it is solely my responsibility, not that of my medical attendants or the NHS, to communicate with the specialists to obtain and send these reports to the AME or CAA as directed in a legible and professional form, generally as multipage PDF.

I understand that if I fail to provide further reports in a suitable form within the specified time frame this may result in an unfit assessment.


I understand that under Med. B. 001 (a) (1) (i) the AME or the CAA can ask for any expert report or medical investigation, and the AME can refer any condition to the CAA.


I understand that if a class 1 is referred to the CAA this applies to the class 2 medical (and LAPL) as well, and that if a class 2 is referred to the CAA this applies to the LAPL as well.


PAYMENT


I am aware that I am paying for the work of the medical, not the certificate, which can only be issued if the medical prerequisites are met, and that I will have to pay for the work of the medical even if I fail to meet these.
I agree that the AME will not be held liable for any costs incurred should relevant medical standards not be met on the day or for any delay for any cause in the issue of the medical certificate and the effect of the delay on licencing, work patterns or pleasure flying.
I agree that the AME will not be held liable for the costs of any further tests, investigations or specialist consultations that may be deemed necessary and that I will therefore remain solely liable for all additional costs incurred, including any referral or processing and administrative fees as charged by the AME.

I further agree that the AME will not be held liable for any additional costs or delays (or consequences thereof) incurred should the medical examination be cancelled or postponed, or if the relevant medical standards are not met, or if specialist reports are delayed, or if casework or communication with the aviation authorities is delayed, or as a result of the absence of the AME due to annual leave, illness, emergency NHS or non-NHS work or any other circumstances.


I understand that I am liable for payment for the entire medical process, including ECG reporting and administration and, if a medical condition is discovered at the assessment that I am responsible for all additional tests, reports and reviews required by the AME or the regulatory authority.

I understand that the AME will also bill for the extra work incurred in processing such reports and that this work is not covered by the fee for the medical examination itself, and agree that I will meet these costs.

I understand that, assuming the AME/ client relationship is not terminated, I will pay for extra work entailed on medical conditions I did not mention in the booking screener email or Cellma application.


I understand that I will be charged for extra work required after medicals (applicable from two weeks from the date of the medical unless agreed otherwise). For FAA medicals, this includes a fee of £50 per specialty for uploading information requested by the AME or by the FAA.

I am aware that if I do not wish to pay this fee then I can transmit the information directly to the FAA by post.
I understand that I will be charged for extra work engendered between medicals.


DECISION MAKING AND APPEALS

I understand that in straightforward medicals the AME is the primary decision maker, and that the AME will be unable to make a fitness decision unless I provide him with the information he requires.


I am aware that in certain conditions the medical must be discussed with the regulatory authorities, at which point they will normally become the decision makers. In some conditions, referral is mandatory. A list of mandatory referral conditions can be found in Part Med B.


I understand that processing complexity takes as long as it takes and I agree to allow the AME time to look at my case, reflect on it, discuss it with colleagues or carry out literature searches; and I agree not to put him under time pressure to assess the case prematurely.


I am aware that I have a right to appeal and understand that I can only exercise this right when a decision has been made, and that the AME is unable to make a fitness decision unless I provide him with the information he requires.


I further understand that if I refuse to provide a report then the only option is to for the AME to refer me as directed by the CAA, either 1/ making me unfit so that I can appeal, or 2/ on-referring for adjudication.


I am aware that the CAA have the right to refuse such referrals (i.e. those where the applicant has not provided the required reports) and that the only course of action possible at such time is that the AME make an unfit assessment (due to lack of information) thus allowing me to trigger the review and appeal process.


I am aware of the review and appeal process and understand that it is my sole responsibility to invoke this and pay for the costs involved.


I understand that if the CAA communicate with me directly (or via the AME) I will be responsible for communicating with them from that point onwards and for paying any additional referral costs as required.


PMD


I understand that Dr John Pitts/ Vision in Aviation Ltd (“the AME”) shall have no part in the Pilot Medical Declaration, which is a process of self-declaration.


Specifically, I understand that if I am assessed unfit based on the assessment above, I cannot then ask the AME if I can self-declare.
Furthermore, I will not send entrapping inquires along the lines of ‘unless I hear from you to the contrary, I will take it that I can self-declare’ or any similar wording.


BETWEEN MEDICALS

I am aware that I have a legal responsibility to report intercurrent illness as defined on the medical certificate to the AME as per Med.A.020.

I am aware that the AME will charge for dealing appropriately with these matters, including giving advice on medication, changing fit status and issuing unfit and fit letters.

I understand that the fees for dealing with such intercurrent illness episodes between medicals are not factored into the fee for the periodic medical examinations themselves.

I confirm that I have studied the fees for such services at www.pilotmedicals.com.

I understand that if I refuse to pay such fees then Dr John Pitts/ Vision in Aviation Ltd (“the AME”) will perform the unfit casework but sever the AME/pilot relationship at this point, meaning that I will have to find another AME to continue my casework and regain my fit status.


DATA


I hereby give my explicit consent for Dr John Pitts and Vision and Aviation Ltd (“the AME”) to collect, process and share my personal data for the purpose of aeromedical regulation.

I understand that the AME has a legal obligation under data protection law (GDPR) to share my personal data with any relevant regulatory bodies, e.g. the UK Civil Aviation Authority and U.S. Federal Aviation Administration, and I specifically consent to the notification of any aviation authority where I am licenced of any health condition

I understand that I can find further information in the AME’s privacy policy at www.pilotmedicals.com. I understand that I may request copies of my medical records at any time in accordance with GDPR and the Data Protection Act (2018).


COMPLAINTS


I understand that Dr John Pitts/ Vision in Aviation Ltd (“the AME”) operate a complaint policy and confirm that if I have a complaint, I will use this policy. I confirm that I will not make oblique threat of complaint such as ‘what is your GMC number’ or ‘are you registered with the GMC’ etc, and I understand that such oblique threats of complaint will terminate the AME/ client relationship.

I am aware that the AME operates a zero-tolerance policy with respect to corrupting, threatening, abusive, or intimidatory language or behaviour and that such language or behaviour will result in the termination of the doctor/ client relationship and notification of the aviation authorities.