Removal of restriction on Medical Certificate in connection with the use of weight loss medication.

Note: Only used if the restriction is imposed due to the use of weight loss medication.

Name	Click here to write tekst.
ID. No.	Click here to write tekst.
Certificate No.	Click here to write tekst.
Class	Click here and choose from drop down
AME No.	Click here to write tekst.
AME name	Click here to write tekst.
Any limitation due to other reasons?	Please state limitation and reason

Medication Name:	Click here to write tekst.
Start date	Choose date.

Reason for the request for removal of restriction (to be filled in by AME) (Mark with x).	Yes	No
1	The use of medication(s) has been stopped for a minimum of two weeks (if yes, questions 3 and 4 are not relevant).
2	There are no other clinical reasons for the restriction(s) being imposed?
3	Have there been inquiries in the review of the health journal due to side effects from the use of the medication?
4	The medication has been used for a minimum of six months, and there are no reports of side effects.
5	Visual acuity and fundoscopy normal?

If the above is answered satisfactorily, and furthermore, no other factors are found that could potentially pose a risk to aviation safety, justifying the maintenance of the restriction, the Danish Civil Aviation and Railway Authority (DCARA) hereby, in accordance with (EU) Regulation 1178/2011, Annex VI, point ARA.MED.125, subparagraph b), Annex IV, point MED.B.001, AMC1 MED.B.001, and AMC2 MED.B.001, subparagraph b), and (EU) Regulation 2015/340, ATCO.AR.F.001, according to Regulation 1178/2011, Annex VI, ARA.MED.125, subparagraph b), and ATCO.MED.B.001, AMC1 ATCO.MED.B.001, and AMC2 ATCO.MED.B.001, authorizes the AME to issue a new medical approval without the following limitation:

Click and choose from drop down.

Click and choose from drop down

If the use of weight loss medication continues, the restriction 'SSL: Copy of all medical records' cannot be removed.

The limitations, if any, previously imposed are continued

For the applicant:

I declare by my signature, under solemn obligation to the DCARA, the accuracy of the clinical information underlying the removal of the above restriction, and that I agree to the removal of the restriction.

By my signature, I also commit to promptly and in accordance with point MED.A.020 in (EU) Regulation 1178/2011 and/or ATCO.MED.A.020 in (EU) Regulation 2015/340, inform an AME if there are changes affecting my health conditions or if new information of significance to my health case comes to my knowledge:

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Applicant Name and Signature.

For AME:

I declare by my signature, under solemn obligation to the DCARA the accuracy of the clinical information underlying the removal of the above restriction, and that I will revoke the applicant's old (yet to expire) medical certificate in compliance with MED.A.030, subparagraph f) in (EU) Regulation 1178/2011 and/or ATCO.MED.A.030, subparagraph b) in (EU) Regulation 2015/340.

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AME stamp and signature.

AME issues a new medical approval, according to the above, and submits a signed copy of this along with a copy of this letter to the DCARA