REFERRAL FORM - NHS WHEELCHAIR This form should be used when a patient needs a wheelchair because of permanent illness or disability lasting more than 6 months. This form must be completed by a G.P., District Nurse or Therapist. When fully completed, please send the form to the Wheelchair Service Administration Team: KCHT Wheelchair Service Tel: 0300 7900128 Administration Team Norman House Please E-mail the completed form to: Beaver Road Ashford. TN23 7SH Service Hours - 09:00 to 17:00 Monday to Friday DO NOT USE - INTERNAL USE ONLY Ashford Heathside Aylesham Medway Dartford DO NOT USE - INTERNAL USE ONLY *Please complete all boxes to avoid unnecessary delays* NHS No: Client Details Title: Mr / Mrs / Miss / Ms / Master OTHER : Forenames: Surname: Date of Birth: Full client postal address: Alternative Contact/Address/Details: Name & Relationship to Client: Address/Details: Postcode: Postcode: Telephone No: Telephone No: Mobile No: Mobile No: E-Mail: E-Mail: GP Name: Address: Telephone Number: Client Ethnicity (From the information you have gained from the client, please indicate by selecting one of the boxes below the client’s ethnicity) A British H Indian B Irish J Pakistani WHITE Any other white C ASIAN K Bangladeshi background Any other Asian L background White and Black D Caribbean E White and Black African M MIXED F White Asian BLACK OR BLACK N African Any other mixed BRITISH Any other Black G P background background PATIENT Patient asked but Z R Chinese ASKED declined OTHER ETHNIC Any other ethnic S category Mental Capacity Act
REFERRAL FORM - NHS WHEELCHAIR This form should be used when a patient needs a wheelchair because of permanent illness or disability lasting more than 6 months. This form must be completed by a G.P., District Nurse or Therapist. When fully completed, please send the form to the Wheelchair Service Administration Team: KCHT Wheelchair Service Administration Team Norman House Beaver Road Ashford. TN23 7SH Tel: 0300 7900128 Please E-mail the completed form to: Service Hours - 09:00 to 17:00 Monday to Friday DO NOT USE - INTERNAL USE ONLY Ashford Heathside Aylesham Medway Dartford DO NOT USE - INTERNAL USE ONLY NHS No: *Please complete all boxes to avoid unnecessary delays* Client Details Title: Mr / Mrs / Miss / Ms / Master OTHER : Forenames: Surname: Date of Birth: Full client postal address: Postcode: Alternative Contact/Address/Details: Name & Relationship to Client: Address/Details: Postcode: Telephone No: Mobile No: E-Mail: Telephone No: Mobile No: E-Mail: GP Name: Address: Telephone Number: Client Ethnicity (From the information you have gained from the client, please indicate by selecting one of the boxes below the client’s ethnicity) WHITE A British ASIAN H Indian B Irish J Pakistani C Any other white background K Bangladeshi L Any other Asian background MIXED D White and Black Caribbean E White and Black African BLACK OR BLACK BRITISH M F White Asian N African G Any other mixed background P Any other Black background PATIENT ASKED Z Patient asked but declined OTHER ETHNIC R Chinese S Any other ethnic category Mental Capacity Act
Wheelchair-Service-referral-Form.docx