Wheelchair Self-Referral Form

Please read before submitting a form

Please note: We will be unable to accept your referral if you are under 18 years of age.

Note on submitting measurements

When submitting height/weight and width please state these measurments as accurately as possible as this will determine the wheelchair you are given.

We won’t be able to appropriately refer a wheelchair to you without these measurements.

Note on powered chairs

Unfortunately we are not able to accept self-referrals for powered chairs if you do not have a wheelchair provided by our service already. We can only accept new referrals for powered chairs from a qualified medical professional.

If you have a wheelchair provided by our service and would like to be assessed for a powered wheelchair, you can contact us on 01429 148049.

Section 1: Personal details

Name(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Date of birth(Required)

We are unable to direct issue equipment to patients under the age of 18 and we would like to offer an assessment

Day

Month

Year

Contact details (Phone or email)(Required)

Diagnosis affecting your mobility(Required)

We do not provide wheelchairs for less than six months, unless you are under palliative care

Please state who provided the diagnosis(Required)

When the diagnosis was provided(Required)

For example, 27 03 2007

Day

Month

Year

Details of services involved:

Details of social service input:

Height(Required)

If you are unable to measure your height, please try through your GP or state N/A

Weight(Required)

If you are unable to weigh yourself, please try through your GP or state N/A

Please be aware that if you are unable to provide a height or weight or you are unable to provide the measurements in Section 3 then you will require an assessment for the provision of a wheelchair

Section 2: Mobility details

How do you transfer:(Required)

How would you describe your ability to sit?(Required)

Do you currently have any pressure ulcers? Or have you had them before?(Required)

If yes, please provide details:

How do you mobilise indoors?(Required)

How do you mobilise outdoors?(Required)

Please provide more information if you would like to

Do you receive any support with either your care or with your mobility?(Required)

If yes with your mobility, are they going to be providing support with a wheelchair from our service?

Please provide details of who is providing the support:

Do you use a wheelchair?(Required)

If you already have a wheelchair provided by wheelchair service then you will need to request a reassessment. You can also do this yourself by contacting us on 01429 522471

Section 3: Wheelchair details

Reason for referral:(Required)

Please be aware that you are unable to self-refer for powered chairs and this requires an assessment. If you are interested in the Personal Wheelchair Budget (PWB) this also requires an assessment.

Please provide measurements of the width of wheelchair you require:(Required)

The seat size is the width of the wheelchair seat. Measure across your lap, outside hip to outside hip without bending the tape measure. Be sure to add 1″/ 2.5cm to promote comfort when sat in the wheelchair.

How many days, on an average week, will you be using the wheelchair?(Required)

What type of wheelchair do you need?(Required)