Medical Equipment Luggage Transport Consent

Patient/Traveler Name:
Date of Birth:
Contact Information:
Medical Equipment Description:
Equipment Serial/ID Number:
Destination(s):
Transport Date(s):

Consent Statement

I, the undersigned, hereby consent to the transport of the listed medical equipment as part of my luggage. I confirm that I have received and understood the guidelines regarding the handling and transport of medical equipment, and accept any responsibilities outlined therein.

Patient/Traveler Signature:
Date:
Witness Signature:
Date: