Profession/Occupation: Contact telephone number: Address: Email: Have you attended a wheelchair Yes No prescriber’s course? If yes, on what date/year: Where was the course?: Consent is required for the wheelchair service to liaise with and obtain information from other professionals involved in the care: client’s Has this consent been obtained? Yes No If yes, who from? Client Carer Parent Date of referral: Please email or post your completed form to the relevant wheelchair service below: Brighton Wheelchair Services Bognor Wheelchair Service Sussex Rehabilitation Centre (Brighton) Richard Hotham Unit Brighton General Hospital Bognor War Memorial Hospital Elm Grove Shripney Road Brighton Bognor Regis BN2 3EX PO22 9PP Tel: 01273 242156/157 Tel: 01243 623650 Fax: 01273 605063 Fax: 01243 623652 Horsham Wheelchair Service Worthing Wheelchair Service Horsham Hospital Sussex Rehabilitation Centre Hurst Road Brighton General Hospital Horsham Elm Grove West Sussex Brighton RH12 2DR BN2 3EX Tel: 01403 227000 ext. 7160 Tel: 01273 265850 Fax: 01273 242016 Fax: 01273 254159 FOR OFFICE USE ONLY Approved by Therapist Signature Date
Profession/Occupation: Contact telephone number: Address: Email: Have you attended a wheelchair prescriber’s course? Yes No If yes, on what date/year: Where was the course?: Consent is required for the wheelchair service to liaise with and obtain information from other professionals involved in the client’s care: Has this consent been obtained? Yes No If yes, who from? Client Carer Parent Date of referral: Please email or post your completed form to the relevant wheelchair service below: Brighton Wheelchair Services Sussex Rehabilitation Centre (Brighton) Brighton General Hospital Elm Grove Brighton BN2 3EX Tel: 01273 242156/157 Fax: 01273 605063 Bognor Wheelchair Service Richard Hotham Unit Bognor War Memorial Hospital Shripney Road Bognor Regis PO22 9PP Tel: 01243 623650 Fax: 01243 623652 Horsham Wheelchair Service Horsham Hospital Hurst Road Horsham West Sussex RH12 2DR Tel: 01403 227000 ext. 7160 Fax: 01273 254159 Worthing Wheelchair Service Sussex Rehabilitation Centre Brighton General Hospital Elm Grove Brighton BN2 3EX Tel: 01273 265850 Fax: 01273 242016 FOR OFFICE USE ONLY Approved by Therapist Signature Date