Client Name: NHS no: GSTT Wheelchair Service Referral Form to be completed by Occupational Therapist and Physiotherapist ONLY All sections in bold MUST be completed. If not completed, the referral will be returned. SECTION 1 CLIENT DETAILS Surname: DOB: / / Date of referral: / / Forename: Male Female HEIGHT & WEIGHT: Address: Height: Weight: Post code: Home Tel: NHS No: Measured OR Estimated Alternative contact / NOK: ↓ Date measured: / / Delivery Address (if different to above): Weight trend: Stable Upward Downward First language: Interpreter required? No Yes SECTION 2 REFERRER & GP DETAILS REFERRED BY: GP DETAILS: Name: GP name: Profession: Address: Address: Tel: Tel: Fax: Fax: Email: Email: Signature: __________________________________ SECTION 3 DIAGNOSIS & REASON FOR REFERRAL DIAGNOSIS & PMHx: Is client inpatient? No Yes Discharge date (mandatory if inpatient): / / *** Without a discharge date, the referral will be returned.*** REASON FOR REFERRAL New Wheelchair User Current Wheelchair User Current Wheelchair Equipment: Reason for review: Alternative seating / Postural equipment in situ (e.g. bed positioning, static seating, standing equipment): Client Name: NHS no: SECTION 4 FUNCTIONAL ABILITY / IMPAIRMENT Comments
Client Name: NHS no: GSTT Wheelchair Service Referral Form to be completed by Occupational Therapist and Physiotherapist ONLY All sections in bold MUST be completed. If not completed, the referral will be returned. SECTION 1 CLIENT DETAILS Surname: DOB: / / Date of referral: / / HEIGHT & WEIGHT: Height: Weight: Measured OR Estimated ↓ Date measured: / / Weight trend: Stable Upward Downward Forename: Male Female Address: Post code: Home Tel: NHS No: Alternative contact / NOK: Delivery Address (if different to above): First language: Interpreter required? No Yes SECTION 2 REFERRER & GP DETAILS REFERRED BY: Name: Profession: Address: Tel: Fax: Email: Signature: __________________________________ GP DETAILS: GP name: Address: Tel: Fax: Email: SECTION 3 DIAGNOSIS & REASON FOR REFERRAL DIAGNOSIS & PMHx: Is client inpatient? No Yes Discharge date (mandatory if inpatient): / / *** Without a discharge date, the referral will be returned.*** REASON FOR REFERRAL New Wheelchair User Current Wheelchair User Current Wheelchair Equipment: Reason for review: Alternative seating / Postural equipment in situ (e.g. bed positioning, static seating, standing equipment): Client Name: NHS no: SECTION 4 FUNCTIONAL ABILITY / IMPAIRMENT Comments
wheelchair-referral-form-therapists.docx