Bexhill arm Left Elevating Left Stump Left Crutch support Right leg rest Right board Right holder Rear wheel position: Footboard Height adjustable arm supports Forward (active) Mid (standard) Other: Anti-Tips Set back (stable) Please provide clinical reasoning for any pressure cushion / accessory requested: SECTION 8 ANY OTHER RELEVANT INFORMATION Return to: GSTT Wheelchair Service, Bowley Close Rehabilitation Centre, Farquhar Road, London, SE19 1SZ Telephone: 020 3049 7760 Email: gst-tr.gsttwheelchairservice@nhs.net
Bexhill arm support Left Right Elevating leg rest Left Right Stump board Left Right Crutch holder Footboard Rear wheel position: Forward (active) Mid (standard) Set back (stable) Height adjustable arm supports Anti-Tips Other: Please provide clinical reasoning for any pressure cushion / accessory requested: SECTION 8 ANY OTHER RELEVANT INFORMATION Return to: GSTT Wheelchair Service, Bowley Close Rehabilitation Centre, Farquhar Road, London, SE19 1SZ Telephone: 020 3049 7760 Email: gst-tr.gsttwheelchairservice@nhs.net
wheelchair-referral-form-therapists.docx