Current Equipment Used What relevant equipment is the client currently Why is this not sufficient? Features Required in New Equipment Please list any specific equipment features required. Please note: not all features are necessarily compatible / possible in one wheelchair. Suppliers often only have one demo item available, which may not be in the required size or features, even if available when scripting / ordering the equipment. Cushion Width: Cushion Depth: Cushion Height: Cushion material: eg. foam, gel, air, combination Pressure risk: eg. as per assessment findings, Waterlow / Braden Scale score If contouring is required, provide details: Does the cushion need to be adjustable to accommodate changing needs? Please circle if any of the cushion needs to accommodate any of the following: Pelvic obliquity / Leg length discrepancy / Incontinence Other: are there any other features required eg. Specific Equipment Requests Please list any specific equipment you wish to view. Please note: although we will endeavour to obtain these for the appointment, there is no guarantee of availability. We can advise you of availability.
Current Equipment Used What relevant equipment is the client currently Why is this not sufficient? Features Required in New Equipment Please list any specific equipment features required. Please note: not all features are necessarily compatible / possible in one wheelchair. Suppliers often only have one demo item available, which may not be in the required size or features, even if available when scripting / ordering the equipment. Cushion Width: Cushion Depth: Cushion Height: Cushion material: eg. foam, gel, air, combination Pressure risk: eg. as per assessment findings, Waterlow / Braden Scale score If contouring is required, provide details: Does the cushion need to be adjustable to accommodate changing needs? Please circle if any of the cushion needs to accommodate any of the following: Pelvic obliquity / Leg length discrepancy / Incontinence Other: are there any other features required eg. Specific Equipment Requests Please list any specific equipment you wish to view. Please note: although we will endeavour to obtain these for the appointment, there is no guarantee of availability. We can advise you of availability.
ILC_AES_Referral_Form_Wheelchairs_Cushions.docx