LIFT Wheelchair Request Form V2.0.26

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1Customer Info

2Mobility Info

3Wheelchair Info

4Medical Info

Please complete the information below of the customer traveling with us that requires Wheelchair Assistance at the airports. All information is required unless marked optional.

Booking Reference Number *

Name and Surname *

Email *

Date of Birth *

Phone *

Mobility

Do you permanently require a wheelchair for mobility? *

Yes, I can't walk
No, I can walk short distances

Can you manage in the cabin without assistance? *

Are you able to fasten your seatbelt unassisted? *

Are you able to feed yourself? *

Are you able to control bladder and bowel functions? *

Do you wear an adult diaper? *

Are you able to climb stairs? *

Can you bend your knee(s) to assume and maintain a standard seated position for the duration of the flight? *

Please provide a valid reason *

Mobility Agreement *

I understand that if I am unable to perform certain activities independently (e.g., using the restroom, move around without assistance), I must travel with a companion to assist me as required for permanently wheelchair-bound passengers. If I have not yet booked my companion’s ticket, I understand that I must do so before my flight.

Mobility Agreement *

I understand that if I am unable to perform certain activities independently (e.g., using the restroom, move around without assistance), I must travel with a companion to assist me. If I have not yet booked my companion’s ticket, I understand that I must do so before my flight.

Wheelchair

Do you have your own wheelchair? *

Wheelchair type *

Manual wheelchair
Battery-operated wheelchair
Mobility scooter
Other (please specify)

Other type *

What type of battery does your wheelchair use? *

Battery Type *

Please specify the type of battery your wheelchair uses

Can your wheelchair battery be detached or disconnected? *

Wheelchair Weight *

Kilograms

Wheelchair Dimension *

W x H x L cm

Please attach a picture of your wheelchair *

Drag & Drop Files, Choose Files to Upload

Please attach a picture of your battery specifications *

Drag & Drop Files, Choose Files to Upload

Medical Info

Do you have any medical conditions? *

Have you had any surgeries in the last 3 months? *

Condition Description *

A brief description of the medical condition or disability requiring assistance

If you have a medical certificate from your doctor, please upload a copy. The certificate should include details of your condition, the assistance required, and any medical equipment you will need onboard.

Upload documents here

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

If you have recently undergone surgery and require medical clearance in line with our Terms and Conditions of Carriage, please upload a letter from your attending doctor confirming that you are fit to fly.

Surgery Description *

A brief description of the medical condition or disability requiring assistance

Please upload a valid medical certificate from your doctor that includes details of your condition, the assistance required, and any medical equipment needed onboard.

Upload documents here *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Acceptance of Terms and Conditions

By submitting this form, you agree to the LIFT Terms and Conditions and Limitations (Article 7.3) of this service. You also confirm that you have read and understood the travel requirements.

Accept T&Cs *

I confirm that I have read and understood the Terms and Conditions for Special Needs and Disabled Travellers.

LIFT Wheelchair Request Form V2.0.26

Wheelchair Assist Request

Mobility

Wheelchair

Medical Info

Acceptance of Terms and Conditions