Hillingdon Wheelchair EPIOC & Specialist Seating Service Woodend Centre Judge Heath Lane Hayes, Middlesex, UB3 2PB Tel: 01895 484 881 Fax: 01895 484 882 Email: [email protected]
Referral Guidance
Please see referral form below to be completed and returned via post or fax.
Please note all sections must be completed, particularly height, weight and diagnosis, so the referral can be processed and accurately screened.
Incomplete referrals will be sent back which may result in a delay of assessment and equipment provision. There is a waiting list to be assessed.
If you would like to hire a wheelchair whilst you are on the waiting list, you can call Medequip on 0208 750 1580.
Hillingdon Wheelchair, EPIOC and Specialist Seating Service
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch
Hillingdon Wheelchair EPIOC & Specialist Seating Service Referral Form Tel: 01895 484 881 Fax: 01895 484 882
Date: ( for office use only) Hi / Ha No:
*Title: Mr / Mrs / Ms / Miss / Master *NHS No:
Other: …………………………………………
*First Name: *Surname:
*Address: *Diagnosis/ Medical condition and date of diagnosis:
*Post code:
*Tel No: *Date of Birth:
Mobile No:
Email:
*Next of Kin: *Height:
*Relationship *Weight:
*Tel No:
*GP: *School name and address:
*Address:
Day Centre: Days attending: M, T, W, Th, F *Tel No:
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch
Alternative contact name/tel. no., to arrange a Do you require an interpreter: Yes No: appointment for assessment:
Language spoken:
Ethnic Group (please complete for monitoring purposes). Please circle
White British White Irish White/Black Caribbean White/Black African White/Asian
Asian Indian Asian Pakistani Asian Bangladeshi Chinese Asian British
Black Caribbean Black African Any other ethnic……………. Any other mixed………………..
Any other white ……………… Any other Asian ………………… Any other Black ......
Religion: …………………………………………………………………………………………………………….
Sexual Orientation. Please tick:
Gay: Gay woman / Lesbian: Heterosexual / Straight: Prefer not to say : Other: *Reason For Referral:
Current equipment:
Able to answer door: Yes: No:
Entry Phone: Key safe: Coded entry: (we will contact you for any codes needed on day) *Frequency of intended use: Daily: Full time: Regular Use: 4 Times a week:
Once a week or less: Occasional: More than 3 hours: Less than 3 hours: seated seated
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch
Where will the wheelchair be used:
Indoor at home: Indoors within a day centre: Outdoors to visit shops / GP:
Indoors and Outdoors: To attend dialysis:
Chair Transfers:
Able to stand: Sliding board: Hoist:
Independent: Assistance from one person: Assistance from two people:
Visual Impairment Yes No Registered blind Registered partially sighted Visual Impairment Wear glasses Wear glasses for reading only Have blackouts / seizures or epilepsy Date of last seizure / epilepsy / blackout ………...... Regular seizures / epilepsy / blackouts
Hearing Impairment Yes No Wear hearing aid/s Need support to communicate in sign language
Pacemaker Yes No Have Pacemaker fitted
Mobility: Indoors: Outdoors: Independent without aids: Independent with walking aids: TYPE: Requires Assistant of Carer: Unable to Walk: Able to do steps / stairs Without assistance: With assistance: Not able: Stair lift: yes: No:
Does the client live alone: Yes: No:
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch
Regular Carer: Yes: No:
Care Agency Name:……………………………………………………………………………………
Carer name: ……………………………………………………………………………………………
Times per week: Tel No:
Type of accommodation: Flat: Maisonette: Floor: Bungalow: House: Nursing / Residential Home: Lift: yes: No:
Parking availability: Yes: No:
Residential / permit parking: Yes/No If yes, please state hours:
Special instructions to property: ……………………………………………………
Free parking: Parking meter:
Access: Is home adapted: Level access: Ramp: Step lift:
Other Professionals Involved
Consultant / Paediatrician /Surgeon Address 1:
Postcode: Telephone Number: Mobile Number: Address 2:
Postcode: Telephone Number: Mobile Number: MEDICATION & ALLERGIES
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch
*Name of referring person:
*Relationship (e.g Therapist, GP, husband, etc):
*Address (in full):
Postcode: Tel No:
Below is to be completed by Applicant or Representative *Do you agree to referral / assessment for a wheelchair: Yes: No:
To improve your Wheelchair Service care, we may need to co ordinate with other professionals involved in your care and support, including your General Practitioner (GP).
Do you give consent for us to share information Yes: No:
Applicants’ signature: Date:
Representative signature: Relationship: Date:
Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch