Delivery Instructions DEP to arrange Prescriber to deliver Other, give details: Special instructions (eg. dogs, telephone to delivery, instructions re equipment for replacement, settings etc): Is this prescription for replacement of an existing item? Yes No If Yes, identify a plan to remove/return existing/unsuitable item: DEP to collect item being replaced or Prescriber to arrange return of item being replaced Other, give details: 7. Equipment Review It is the prescribing therapist’s responsibility to ensure correct fitting and client education for DEP equipment on issue. In addition, planned review is recommended within 12 weeks of delivery and use. Please indicate mode of review arranged for equipment following issue: Home visit Telephone Call Client to contact prescriber as needed Other (state details of referral made for follow up, as required): 8. Resources Please attach relevant Resources for this prescription. Refer to Clinical Guidelines. Required Resources for powered wheeled mobility aid attached: Cognitive screen Yes No Vision assessment Yes No Driving assessment Yes No If required, Resources for manual wheeled mobility aid attached Yes No Comment: 9a. Prescriber Details Print and sign to complete Prescriber Approved Prescriber Name: No.: I declare that I am an Approved Prescriber of the appropriate level to prescribe this equipment according to the DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. OR I declare that I have completed this prescription which has been endorsed by an Approved Prescriber of an appropriate level to prescribe this equipment, according to DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. Signature: Date: / /
Delivery Instructions DEP to arrange Prescriber to deliver Other, give details: Special instructions (eg. dogs, telephone to delivery, instructions re equipment for replacement, settings etc): Is this prescription for replacement of an existing item? Yes No If Yes, identify a plan to remove/return existing/unsuitable item: DEP to collect item being replaced or Prescriber to arrange return of item being replaced Other, give details: 7. Equipment Review It is the prescribing therapist’s responsibility to ensure correct fitting and client education for DEP equipment on issue. In addition, planned review is recommended within 12 weeks of delivery and use. Please indicate mode of review arranged for equipment following issue: Home visit Telephone Call Client to contact prescriber as needed Other (state details of referral made for follow up, as required): 8. Resources Please attach relevant Resources for this prescription. Refer to Clinical Guidelines. Required Resources for powered wheeled mobility aid attached: Cognitive screen Yes No Vision assessment Yes No Driving assessment Yes No If required, Resources for manual wheeled mobility aid attached Yes No Comment: 9a. Prescriber Details Print and sign to complete Prescriber Name: Approved Prescriber No.: I declare that I am an Approved Prescriber of the appropriate level to prescribe this equipment according to the DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. OR I declare that I have completed this prescription which has been endorsed by an Approved Prescriber of an appropriate level to prescribe this equipment, according to DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. Signature: Date: / /
P-6%20Wheeled%20Mobility%20Aids.docx