Request date: URGENT Short term loan (3 months or less) Long term loan INFORMATION At-Home Program In–Care Other Child Name: Weight/Height: Birthdate: Phone: Parent/Guardian: Address: Ship To: Professional Designation: Facility/Organization: Phone: Fax: E-Mail: EQUIPMENT *************************************************************** (Subject to availability) ********************************************************** Scooter Type * WHEELCHAIR (subject to availability) (check all those that apply) Type: rigid SEATING in space recline No seating required, client has custom seating transport hemi-height Cushion: type power With transit option size other Backrest: type size Seat width Head Support: type seat to back height floor size Seating: none same as spec form mounting type Armrests: adjustable removable Comments: flip-back full/desk length other TOILETTING AIDS Hangers: 60” 70” 80” Raised Toilet Seat: clamp on bubble with arms 2” 4” swing away removable Commode: wheeled stationary elevating/smartleg shower tilt Footrests: composite adjustable type size plate ” Brakes: push pull size extensions attendant Height of seat from ” Wheels: 12” 18” 20” * (if available) * (subject to STF) Toilet Safety Frame: Standard air polyurethane solid Paediatric Toilet Support: size: ” mag-rim spoke rim model: Casters: 3” 4” 5” height back low back padded unpadded * (subject to STF) Other Comments: (only available in 8”) BATHING AIDS rims Tub Transfer Bench: padded unpadded Options: seat belt type either handles huggers Arm on right left Bath Chair: back no back chest strap tray size Bath Board: flush raised other Tub Grip: model Powerchair Options Bath Tub Lift: Joystick: left right center attendant Drive: center rear front Paediatric Bath Seat: model size Tilt: manual electric
Request date: URGENT Short term loan (3 months or less) Long term loan INFORMATION At-Home Program In–Care Other Child Name: Weight/Height: Birthdate: Phone: Parent/Guardian: Address: Ship To: Professional Designation: Facility/Organization: Phone: Fax: E-Mail: EQUIPMENT *************************************************************** (Subject to availability) ********************************************************** WHEELCHAIR (check all those that apply) Type: rigid in space recline transport hemi-height power With transit option other Seat width seat to floor back height Seating: none same as spec form Armrests: adjustable removable flip-back full/desk length other Hangers: 60” 70” 80” swing away removable elevating/smartleg Footrests: composite adjustable plate Brakes: push pull extensions attendant Wheels: 12” 18” 20” * (subject to STF) air polyurethane solid mag-rim spoke rim Casters: 3” 4” 5” * (subject to STF) (only available in 8”) rims Options: seat belt type handles huggers chest strap tray size other Powerchair Options Joystick: left right center attendant Drive: center rear front Tilt: manual electric Scooter Type * (subject to availability) SEATING No seating required, client has custom seating Cushion: type size Backrest: type size Head Support: type size mounting type Comments: TOILETTING AIDS Raised Toilet Seat: clamp on bubble with arms 2” 4” Commode: wheeled stationary shower tilt type size size ” Height of seat from ” * (if available) Toilet Safety Frame: Standard Paediatric Toilet Support: size: ” model: height back low back padded unpadded Other Comments: BATHING AIDS Tub Transfer Bench: padded unpadded either Arm on right left Bath Chair: back no back Bath Board: flush raised Tub Grip: model Bath Tub Lift: Paediatric Bath Seat: model size
2-1-3-3c_bc_-cmerls-request-form_non-biomed.docx