IMPORTANT - SPECIAL NEEDS INFORMATION
Please return this form to us by ------as we will not be able to confirm your holiday arrangements until we receive this information. Please do not detach this sheet.
As a reputable operator, we would like all of our clients to enjoy completely successful travel arrangements. If you have a medical condition or disability requiring special travel, accommodation, transfer or dietary arrangements, please complete this questionnaire. We will use this information to check the suitability of all components of your itinerary before we issue our confirmation invoice.
In completing and returning this form to us, we understand that you are providing permission for us to relay the information contained to the suppliers of your holiday components, such as airlines, hotels, transfer agents, etc. Some airlines may also require you to complete one of their own medical forms together with notes from your GP.
Please ensure that you provide as much detail as possible and use the sections provided for any additional information which may help us to help you. If necessary please attach a separate sheet of paper.
Please check that your holiday insurance policy adequately covers any pre-existing medical condition and covers any expensive equipment you may be taking.
Lead Name: / Customer Name with special needs:Booking/Quote Ref: / Special Needs Ref: / Departure Date:
Hotel name: / Destination:
SPECIAL NEEDS INFORMATION
1. What is the nature of your disability/special need? Please give the dates
and details of any onset / recurrence of illness, and of any operations you may have had. Please name any medication you are currently taking. If you have mobility difficulties please give details: ______
______
______
A.GENERAL MOBILITY Tick as appropriate
2.Can you walk on your own without assistance? Yes No
If so, approx distance ______
3.Will you be accompanied by a professional carer? Yes No
4.Are you totally confined to a wheelchair/scooter? Yes No
5aAre you taking your own wheelchair? Yes No
5b. Are you taking your own motorised scooter Yes No
6a.Is it collapsible? Yes No
6b.Is it battery operated? Yes No
6c.If so, is it: Wet cell Yes Dry cell Yes
7.What are the dimensions and weight of your wheelchair/scooter?
Open: Width ...... ins Height ...... ins Depth...... ins Weight......
Closed: Width ...... ins Height ...... ins Depth ...... ins
B. TRAVEL ARRANGEMENTS
8.Airlines are normally able to provide the following types of assistance. Please indicate which is most suitable for you:
a)Wheelchair to and from aircraft – can climb aircraft steps and
make own way to seat.
b)Wheelchair to and from aircraft, assistance with aircraft steps
(cannot climb) can make own way on aircraft.
c)Wheelchair required all way to cabin seat – lift onto aircraft,
(NB this may not be possible on all types of aircraft).
d)No airport assistance required – can climb aircraft steps (approx
10-15 steps).
9.Can you attend to your own needs on the aircraft? Yes No
10.Will you be taking medication during the flight? Yes No
If so please give names of any medication you are taking. Do you need any stored on the flight?
______
11.Are you taking any medical equipment? Yes No
If so - what & what size?
______
- Are you asthmatic or do you have other Yes No
breathing difficulties? Please give details:
______
13.Do you have any leg/heart problems? Yes No
(i.e. amputee(state which leg)/leg needs to be raised/supported/angina/stroke etc)
Please give details:
______
14.Is it best for you to have an aisle seat? Yes No
Do you have any specific seat requests? (Please bear in mind these cannot be guaranteed):
______
Please note, exit seats will only be allocated to fully able-bodied, adult passengers.
15.Do you have any further special flight requirements? Please give details: ______
A.TRANSFER INFORMATION
(where included in your holiday or booked by you)
16. Our standard transfer are provided by Coach or Minibus- Please advise if this acceptable
Yes No
OR- do you require a private car transfer /or disabled access vehicle- please advise as below There may be an additional charge for this ______
Remember, you, your party, your luggage and wheelchair will need to be transferred – if a car is required will one vehicle be enough Yes No
If you have not booked transfers with Premier Holidays, and they are not included in your travel itinerary, and you would like to add them to your reservation, please contact us to arrange this for you. If transfers are not included as part of your holiday, we may be able to add these, at the appropriate cost.
B.ACCOMMODATION
17.Can you walk up/down steps? Yes No
Approximately how many? ______
18.Do you have a specific requirement regarding room location? If yes, please give details:
______
Please bear in mind few hotels offer ground floor rooms – you may wish to request a room near a lift.
19.Would you like medication to be stored in a fridge? Yes No
If yes, what is it and when will you need access to it?
______
20.Does a wheelchair need to go into the bathroom? Yes No
21.Do you need a bath? Yes No or shower? Yes No
If your preference is not available, will the other be acceptable? Yes No
If you require a shower, is it acceptable if it is over the bath? Yes No
Please bear in mind that very few hotels have shower cubicles and even fewer have “walk-in” showers which do not have a lip. Please give details below if this will present a problem for you.
______
22.Do you require any special equipment? Yes No
If yes, please give details:
______
(Charges may be applicable and we cannot guarantee availability)
The majority of hotels do not have specifically adapted facilities for the disabled and you may be required to ‘adapt’ to existing facilities. They are standard hotels with standard facilities, which, because of their location, or size of rooms, may be more appropriate than others.
23.In order to assist us in ensuring that these will be suitable, please detail any special needs or information which may help us. (Remember that even bathrooms large enough for wheelchair access may have limited space for manoeuvring.)
______
______
E. MEALS
24.Do you have a special dietary requirement? Yes No
If yes, please give details for both flights and accommodation: ______
______
The completion of this form is not a guarantee that all special needs and requests will be met. This will however enable Premier Holidays to ensure that we have taken all possible precautions to make your holiday as enjoyable as possible. As such, please complete the customer declaration below.
F.CUSTOMER DECLARATION
I confirm that I have detailed any special needs I have on this form and understand that this is the information (and no other) which will be made available to the suppliers. If I wish to amend or add any information at a later stage, I will ensure I do so in writing.
Your Signature:______Date: ______
Print name:______
Please return to:
Premier Holidays, Westbrook, Milton Road, Cambridge, CB4 1YG
Phone: 01223 516333 Fax: 01223 516615
E-mail:
Premier air
CID Air