<p> 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]</p><p>Referral Guidance</p><p>Please see referral form below to be completed and returned via post or fax. </p><p>Please note all sections must be completed, particularly height, weight and diagnosis, so the referral can be processed and accurately screened. </p><p>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.</p><p>If you would like to hire a wheelchair whilst you are on the waiting list, you can call Medequip on 0208 750 1580.</p><p>Hillingdon Wheelchair, EPIOC and Specialist Seating Service</p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch</p><p>Hillingdon Wheelchair EPIOC & Specialist Seating Service Referral Form Tel: 01895 484 881 Fax: 01895 484 882</p><p>Date: ( for office use only) Hi / Ha No: </p><p>*Title: Mr / Mrs / Ms / Miss / Master *NHS No:</p><p>Other: …………………………………………</p><p>*First Name: *Surname: </p><p>*Address: *Diagnosis/ Medical condition and date of diagnosis:</p><p>*Post code: </p><p>*Tel No: *Date of Birth: </p><p>Mobile No: </p><p>Email:</p><p>*Next of Kin: *Height: </p><p>*Relationship *Weight: </p><p>*Tel No: </p><p>*GP: *School name and address:</p><p>*Address: </p><p>Day Centre: Days attending: M, T, W, Th, F *Tel No: </p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch</p><p>Alternative contact name/tel. no., to arrange a Do you require an interpreter: Yes No: appointment for assessment:</p><p>Language spoken:</p><p>Ethnic Group (please complete for monitoring purposes). Please circle </p><p>White British White Irish White/Black Caribbean White/Black African White/Asian </p><p>Asian Indian Asian Pakistani Asian Bangladeshi Chinese Asian British</p><p>Black Caribbean Black African Any other ethnic……………. Any other mixed………………..</p><p>Any other white ……………… Any other Asian ………………… Any other Black ...... </p><p>Religion: …………………………………………………………………………………………………………….</p><p>Sexual Orientation. Please tick:</p><p>Gay: Gay woman / Lesbian: Heterosexual / Straight: Prefer not to say : Other: *Reason For Referral: </p><p>Current equipment:</p><p>Able to answer door: Yes: No: </p><p>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: </p><p>Once a week or less: Occasional: More than 3 hours: Less than 3 hours: seated seated</p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch</p><p>Where will the wheelchair be used:</p><p>Indoor at home: Indoors within a day centre: Outdoors to visit shops / GP: </p><p>Indoors and Outdoors: To attend dialysis: </p><p>Chair Transfers:</p><p>Able to stand: Sliding board: Hoist: </p><p>Independent: Assistance from one person: Assistance from two people: </p><p>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</p><p>Hearing Impairment Yes No Wear hearing aid/s Need support to communicate in sign language</p><p>Pacemaker Yes No Have Pacemaker fitted </p><p>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: </p><p>Does the client live alone: Yes: No: </p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch</p><p>Regular Carer: Yes: No: </p><p>Care Agency Name:……………………………………………………………………………………</p><p>Carer name: …………………………………………………………………………………………… </p><p>Times per week: Tel No:</p><p>Type of accommodation: Flat: Maisonette: Floor: Bungalow: House: Nursing / Residential Home: Lift: yes: No: </p><p>Parking availability: Yes: No: </p><p>Residential / permit parking: Yes/No If yes, please state hours:</p><p>Special instructions to property: ……………………………………………………</p><p>Free parking: Parking meter: </p><p>Access: Is home adapted: Level access: Ramp: Step lift: </p><p>Other Professionals Involved</p><p>Consultant / Paediatrician /Surgeon Address 1:</p><p>Postcode: Telephone Number: Mobile Number: Address 2:</p><p>Postcode: Telephone Number: Mobile Number: MEDICATION & ALLERGIES</p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch</p><p>*Name of referring person: </p><p>*Relationship (e.g Therapist, GP, husband, etc): </p><p>*Address (in full): </p><p>Postcode: Tel No:</p><p>Below is to be completed by Applicant or Representative *Do you agree to referral / assessment for a wheelchair: Yes: No: </p><p>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).</p><p>Do you give consent for us to share information Yes: No: </p><p>Applicants’ signature: Date: </p><p>Representative signature: Relationship: Date: </p><p>Chair: Dame Ruth Runciman Chief Executive:Claire Murdoch </p>