Review of existing equipment form

Please note we DO NOT provide the following:

Wheelchairs into hospital/rehabilitation settings
Transit chairs into nursing home
Outdoor only powered chairs or scooters

The Review form will be reviewed by the Wheelchair Service Team once submitted. You may then be contacted to discuss the form further.

This form is for existing equipment, for new referrals please fill out our Wheelchair service referral form.

Who is the review for? *

Myself
Someone else

Are you a

Friend / Family member / Neighbour
GP / Other Professional

Referrers Details

Title

Full Name

Relationship to Service User

Is the Service User aware of this referral being made?

Contact number

Professional Details

Name

Profession

Address and Postcode

Email Address

Contact Number

Is the Service User aware of this Referral being made?

Hospital Information

Is the person in Hospital?

Planned discharge date

Day Month Year

Personal Details

Title *

Full Name *

Date of Birth *

Day Month Year

Gender *

Male
Female

NHS number *

Address *

Postcode *

What best describes address provided? *

Home Address
Nursing/Care Home
Other

Main Contact number *

Additional contact numbers

Email address *

What is your height (ft) *

What is your weight (kg) *

Reason for requesting a review? *

GP Details

GP Surgery *

Address *

Contact Number *

Type of Wheelchair

What type of chair are you requesting? * Please note your request will be assessed against Wheelchair Service Criteria

Attendant propelled chair (transit)
Self propelling chair
Indoor powered chair
Indoor outdoor powered chair
Buggy
Not Known

Is the client fit to Self Propel

Seat Width

Seat Depth

Any additional information

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