Issuance of Medical Certificate with limitation after starting weight loss medication.

Note: Form must be used despite already having OML, OSL, MCL, and SSL limitations om the certificate due to other reasons.

Name	Click here to write text.
ID No.	Click here to write text.
Certificate No.	Click here to write text.
Class	Click here and choose from dropdown
AME No.	Click here to write text.
AME Name	Click here to write text.
Any limitation due to other reasons?	Please state limitation and reason.

Medication Name:	Click here to write text.
Start Date	Choose date.

Clinical information and examinations. (to be filled out by AME) (mark with x)	Yes	No
1	Has the medication(s) been used for four weeks according to regulations?
2	Are there side effects experienced from the use of the medication that could lead to acute incapacitation?
3	Visual acuity and fundoscopy normal?
4	Have there been inquiries in the review of the health journal due to side effects from the use of the medication?
5	AME assesses that the applicant has side effects or other health conditions that may jeopardize aviation safety.

If the above is answered satisfactorily, and furthermore, no other factors are found that could potentially pose a risk to aviation safety, the Danish Civil Aviation and Railway Authority (DCARA) assesses that the applicant does not fully meet the requirements for the relevant medical certification class but is not considered to jeopardize the safe exercise of the relevant certificate's rights, as stated in respectively (EU) Regulation 1178/2011, MED.B.001, and (EU) Regulation 2015/340, ATCO.MED.B.001.

On this basis, the DCARA, 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, hereby grants AME the authority to issue a new medical certificate, with the following limitation:

Clik here and Choose limitation from the drop down

SSL: Copy of all medical records to AME

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 decision to impose the above restrictions, and that I agree to their imposition.

By my signature, I also commit to promptly and in accordance with 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 imposition of the above restrictions, 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.