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Wheelchair service referral 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 Referral 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 new referrals, for existing referrals please fill out the review of existing equipment form.

Who is the referral for? *
Are you a

Note: Complete the following information as you, the referrer.

Referrers Details
Is the Service User aware of this referral being made?
Please input your contact number if you are the main point of contact for this Referral
Hospital Information
Is the person in Hospital?
Planned discharge date
Professional Details
Is the Service User aware of this Referral being made?
Personal Details
Date of Birth *
Gender *
What best describes address provided? *
GP Details
Type of Wheelchair
What type of chair are you requesting? * Please note your request will be assessed against Wheelchair Service Criteria
Required Wheelchair duration
Is the Wheelchair required for more than 6 months?
Clinical information
Is there a history of Pressure Areas?
Functional Abilities
What activities do you need to do in a wheelchair?
How would / do you transfer in and out of the wheelchair?
Walking ability
Balance when seated in a wheelchair / armchair
How often will the wheelchair be used (approximately, on average)
Terms and conditions *

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