<p> Referral form for Liverpool Wheelchair Service All sections of this form are mandatory; incomplete forms will be returned to the referrer.</p><p>Relevant Medical History:</p><p>Please describe the applicants current mobility, including any mobility aids used  Indoors:</p><p> Outdoors:</p><p>Please describe your method of transfer (e.g. independent, hoist, assistance):</p><p>Name: D.O.B:</p><p>Does the applicant have any visual impairment? If yes please give details:</p><p>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):</p><p>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]</p><p>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.</p><p>Personal Details:</p><p>Medical Information:</p><p>1 Draft v1 July 2014</p><p>Lifehouse, Brunswick Business Park, Summers Height: Weight:</p><p>Social Information: Does the applicant have a carer who will push the wheelchair? Yes  No </p><p>Are there any health issues for the carer? (If yes please give details)</p><p>How often will the chair be used?</p><p>Where will the chair be used? Indoors  Outdoors  Both </p><p>2 Draft v1 July 2014 Does the client currently have a wheelchair from Liverpool Wheelchair Service?</p><p>Yes  No  Not Known </p><p>If the applicant already has a wheelchair, please state reason for re-referral:</p><p>If the applicant already has a wheelchair, please describe the type of wheelchair and cushion on issue: </p><p>Application For:</p><p>Attendant-Propelled Wheelchair (pushed by carer) </p><p>Self-Propelled Wheelchair (pushed by self) </p><p> If referral is from a medical professional please state if applicant is medically fit to self- propel: Yes  No </p><p>Electric Powered Indoor Only Wheelchair  </p><p>Electric Powered Indoor/Outdoor Wheelchair  (Powered chairs for outdoor only use are NOT supplied) </p><p>Customised Special Seating </p><p>Voucher Scheme </p><p>Childs pushchair or buggy </p><p>Has the applicant consented to this referral? Yes  No  If no, please give reason: ______</p><p>Additional Information to support referral if required:</p><p>Name: D.O.B:</p><p>Ethnicity: 3 Draft v1 July 2014 Black or Black British Chinese or Chinese British □ African □ Chinese □ Caribbean □ Any other Black background</p><p>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</p><p>White □ British □ Irish</p><p>□ Any other ethnicity (please describe) ______□ Do not wish to disclose</p><p>Referrer Details: Name:</p><p>Designation/Relationship to applicant:</p><p>Address (if referring professional):</p><p>Telephone number:</p><p>Date:</p><p>4 Draft v1 July 2014</p>