DEP Prescription Form (Part A) DEP P-6 Wheeled Mobility Aids Please nominate the equipment this prescription is for: Level 1 General Equipment - DO NOT complete Section 3 Trial 2 General or Seating Equipment - COMPLETE ALL SECTIONS Any item that is not on the DEP Approved Equipment List - COMPLETE ALL SECTIONS If completing multiple Prescription Forms for Multiple Equipment Types do not complete section 1B ATTACH – P-C PRESCRIPTION COVERSHEET 1a. Client Details Client ID: Is the applicant an existing DEP client? Yes No Unsure 1b. Further Client Details (Required for single Equipment Type prescription only) A DEP Application Form is required for all new applicants, and existing clients CRN whose situation has changed or requires confirmation (Special Consideration) (Pension No.): Surname: Trial Names: Preferred : Phone: Email: Date of Birth: / / Residential Address: Postal Address (if different): Parent/Guardian (if applicable): Contact Details (if different): Client Diagnosis and Details of Functional Disability: 2. Identification of Need/Clinical Criteria State the clinical criteria that relates to this equipment request: Provide information from the clinical and functional assessment of relevant skills including physical, sensory and cognitive considerations Please as relevant: ‘check’ Manual Wheelchair: Client is unable to walk safely to achieve their functional goals; AND A wheelchair is the client’s primary means of mobility; OR Client is a mixed mobility user; AND
DEP Prescription Form (Part A) DEP P-6 Wheeled Mobility Aids Please nominate the equipment this prescription is for: Level 1 General Equipment - DO NOT complete Section 3 2 General or Seating Equipment - COMPLETE ALL SECTIONS Any item that is not on the DEP Approved Equipment List - COMPLETE ALL SECTIONS If completing multiple Prescription Forms for Multiple Equipment Types do not complete section 1B – ATTACH P-C PRESCRIPTION COVERSHEET 1a. Client Details Client ID: Is the applicant an existing DEP client? Yes No Unsure 1b. Further Client Details (Required for single Equipment Type prescription only) CRN (Pension No.): A DEP Application Form is required for all new applicants, and existing clients whose situation has changed or requires confirmation (Special Consideration) Surname: Names: Preferred Phone: : Email: Date of Birth: / / Residential Address: Postal Address (if different): Parent/Guardian (if applicable): Contact Details (if different): Client Diagnosis and Details of Functional Disability: 2. Identification of Need/Clinical Criteria State the clinical criteria that relates to this equipment request: Provide information from the clinical and functional assessment of relevant skills including physical, sensory and cognitive considerations Please ‘check’ as relevant: Manual Wheelchair: Client is unable to walk safely to achieve their functional goals; AND A wheelchair is the client’s primary means of mobility; OR Client is a mixed mobility user; AND Trial Trial
P-6%20Wheeled%20Mobility%20Aids.docx