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Date
To Whom it May Concern:
_________________ (Patient's full name) suffers from a life-threatening
allergy to the following allergens: _______________________________________________________________________
In this medical condition (anaphylaxis) severe reactions can be unpredictable
and follow exposure to even minute amounts of allergen. Life-saving injectable
medication (epinephrine / EpiPen®) has been prescribed to _______________________
(Patient's name) by a licensed medical practitioner with the understanding
that it will be immediately available at all times. If a reaction occurs,
it is critical that the injection be given immediately in order to stop
progression. Delayed treatment of such a reaction would be particularly
hazardous mid-flight and could lead to a forced landing and, possibly,
death. As immediate use of EpiPen® can be life saving, please allow
_________________ (Patient's full name) to carry EpiPen®(s) on board
the airplane.
Additional information may be obtained from ________________________ (Physician's
Name) at ____________ (Phone) or ___________ (Fax)
Respectfully,
____________________________________________, M.D.
M.D. OFFICE STAMP
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