Referral Form for Liverpool Wheelchair Service

Referral form for Liverpool Wheelchair Service All sections of this form are mandatory; incomplete forms will be returned to the referrer.

Relevant Medical History:

Please describe the applicants current mobility, including any mobility aids used  Indoors:

 Outdoors:

Please describe your method of transfer (e.g. independent, hoist, assistance):

Name: D.O.B:

Does the applicant have any visual impairment? If yes please give details:

Does the applicant have any pressure areas / skin redness, or have they had in the past? Please include grade and location if known (if nil please mark as such):

The telephone number for this service if you wish to discuss your referral is 0151 296 7770. Please return this form via fax; 0151 296 7764, post; Liverpool Wheelchair Service, Lifehouse, Brunswick Business Park, Summers Road, Liverpool, L3 4BL or email; [email protected]

Referrals are only accepted for clients with a long-term mobility need. This service does not provide wheelchairs for short-term loan or occasional/ social use.

Personal Details:

Medical Information:

1 Draft v1 July 2014

Lifehouse, Brunswick Business Park, Summers Height: Weight:

Social Information: Does the applicant have a carer who will push the wheelchair? Yes  No 

Are there any health issues for the carer? (If yes please give details)

How often will the chair be used?

Where will the chair be used? Indoors  Outdoors  Both 

2 Draft v1 July 2014 Does the client currently have a wheelchair from Liverpool Wheelchair Service?

Yes  No  Not Known 

If the applicant already has a wheelchair, please state reason for re-referral:

If the applicant already has a wheelchair, please describe the type of wheelchair and cushion on issue:

Application For:

Attendant-Propelled Wheelchair (pushed by carer) 

Self-Propelled Wheelchair (pushed by self) 

 If referral is from a medical professional please state if applicant is medically fit to self- propel: Yes  No 

Electric Powered Indoor Only Wheelchair 

Electric Powered Indoor/Outdoor Wheelchair  (Powered chairs for outdoor only use are NOT supplied)

Customised Special Seating 

Voucher Scheme 

Childs pushchair or buggy 

Has the applicant consented to this referral? Yes  No  If no, please give reason: ______

Additional Information to support referral if required:

Name: D.O.B:

Ethnicity: 3 Draft v1 July 2014 Black or Black British Chinese or Chinese British □ African □ Chinese □ Caribbean □ Any other Black background

Dual Heritage Asian or Asian British □ Asian and White □ Bangladeshi □ Black African and White □ Indian □ Black Caribbean and White □ Pakistani □ Chinese and White □ Any other Asian background □ Any other duel heritage background

White □ British □ Irish

□ Any other ethnicity (please describe) ______□ Do not wish to disclose

Referrer Details: Name:

Designation/Relationship to applicant:

Address (if referring professional):

Telephone number:

4 Draft v1 July 2014