Accessories Needed: Bath Support: padded unpadded high back low back size WALKING AIDS Other Comments: (see over) Walker size: ” Handle height ” TRANSFER AIDS 2 wheels 4 wheels Grab bar(s): describe and mark location brakes brakes Wall Mounted Floor Mounted locks back wheels 12” 18” 24” Gait Trainer model size Other location accessories required Handipole:height location Cane height handle type and do LOJ to MCFD with quote for Installation type: quad single point Trapeze Bar: freestanding to bed Crutches Patient Lift: hydraulic floor floor height type ceiling Type size ” BEDS/MATTRESSES OT must be present for lift delivery Hospital Bed: manual full-electric Comments: semi-electric trendelenberg reverse trendelenberg THERAPY EQUIPMENT Type Of Mattress: size Ball: size type Peanut: size ” Wedge: width foam mattress height alternating pressure rise low air loss Rolls: diameter Roho # of sections needed length Sofflex Mat: width levelling sections # of sections needed length overlay description thickness Bed Rails: full half Other bed assist bar over bed table comments Other Comments: ENVIRONMENTAL FURNITURE Other equipment not listed above: width depth STF ” ” ” type use with seating N Corner Seat: back height size ” ” size Table: width depth cut-out ” ” ” ************************************ SECTION TO BE (THIS Height Range Required: COMPLETED BY CMERLS OFFICE) Angle Adjustment Required N *********************************** Other comments: Option Available: STROLLER RCID#: Description: style/light weight jogger speciality stroller all-terrain reclining NOT AVAILABLE AT THIS TIME PLEASE PROCEED model size – WITH DEALER TRIAL Other Comments Comments/Special Instruction STANDERS size: Accessories Required: Other Comments :
Accessories Needed: Bath Support: padded unpadded high back low back size Other Comments: (see over) TRANSFER AIDS Grab bar(s): describe and mark location Wall Mounted Floor Mounted 12” 18” 24” Other location Handipole:height location and do LOJ to MCFD with quote for Installation Trapeze Bar: freestanding to bed Patient Lift: hydraulic floor floor ceiling Type size ” OT must be present for lift delivery Comments: THERAPY EQUIPMENT Ball: size type Peanut: size Wedge: height width rise Rolls: length diameter Mat: length width thickness Other comments ENVIRONMENTAL FURNITURE width ” depth ” STF ” type use with seating N Corner Seat: size ” back height ” size Table: width ” depth ” cut-out ” Height Range Required: Angle Adjustment Required N Other comments: STROLLER style/light weight jogger speciality stroller all-terrain reclining model size Other Comments STANDERS size: Accessories Required: Other Comments : WALKING AIDS Walker size: ” Handle height ” 2 wheels 4 wheels brakes brakes locks back wheels Gait Trainer model size accessories required Cane height handle type type: single point quad Crutches height type BEDS/MATTRESSES Hospital Bed: manual full-electric semi-electric trendelenberg reverse trendelenberg Type Of Mattress: size ” foam mattress alternating pressure low air loss Roho # of sections needed Sofflex levelling sections # of sections needed overlay description Bed Rails: full half bed assist bar over bed table Other Comments: Other equipment not listed above: ************************************ (THIS SECTION TO BE COMPLETED BY CMERLS OFFICE) *********************************** Option Available: RCID#: Description: NOT AVAILABLE AT THIS TIME – PLEASE PROCEED WITH DEALER TRIAL Comments/Special Instruction
2-1-3-3c_bc_-cmerls-request-form_non-biomed.docx