This form can be used to request an FAA exam. If you have previously been seen by Dr. Zwaan, log in to the portal if you can. (Inside the portal you can pick an exact date and time.)
Once we have received this form, we will contact you and either arrange an appointment or give you access to our portal to book or change your appointment on your own.
The fields with an asterisk are required fields. We have kept the required fields to a minimum, but the more information you provide, the easier it will be to arrange your appointment.
your medical certificate should preferably include your full middle name
Strongly encouraged for new applicants. With your e-mail, we can assign you a username and send you reminders. Returning applicants can skip if unchanged.
First class exam requires a baseline ECG after you turn 35, and then annually after the age of 40.
First and Second class exams require vision correctible to 20/20. Third class exams require vision correctible to 20/40. If this is your first exam and you wear contacts, bring a container and supplies to remove them during the exam. Bring glasses if you have them, just in case.
Note: special issuance exams or new conditions frequently require submission of reports.
Our office is generally open Monday - Wednesday from 9:00 - 12:30 and 1:30 - 5:00, Friday from 9:00 - 12:30 and 1:30 - when I feel like going home.
(Use this if you are flexible about the time on that day.)
If that date doesn't work, give us a range of dates below if you wish, or use the comment field at the bottom of the form.
e.g. morning, afternoon, earliest or latest available?
Keep it short. We'll talk about it at the appointment.
Prior to your appointment, you will need to complete your part of the FAA medical application on the FAA web site (see link below). When you "save" the exam, NOTE THE CONFIRMATION NUMBER AND BRING A COPY OF THE EXAM (most pilots now save a copy on their phone). We need the confirmation number to issue a certificate, so feel free to e-mail it to us in advance. It is also good to have access to a copy of the exam in case there is a problem with our computers or the internet.
These links are FYI only. Complete and send this form even if you have not yet done your medxpress application.
FAA main website: www.faa.gov
FAA medXpress Log in window: https://medxpress.faa.gov/
If you have already completed the medxpress application, and wish to forward the confirmation number in advance, you can do so now on this form to speed up registration. Otherwise, e-mail it or bring it with you at the time of your appointment. Regardless of how or when you do it, we will not access your application until you arrive in our office.
only if you already have it.
Thank you for completing this form. Submit this form and await reply.
Contact our office again if you have not heard from us in 3 working days. (email: firstname.lastname@example.org or email@example.com )