Derbyshire Wheelchair Service
Version Date: / 01/04/14
Review Date: / 01/04/15
Wheelchair Referral Form for Manual Chairs
The Derbyshire Wheelchair Service provides appropriate equipment for people with a long term need only
Derbyshire Wheelchair ServiceSouth – Derbyshire Wheelchair Service
The Manor,
Manor Park Way,
DERBY, DE22 3NB
Tel: 01332 287057 Fax 01332 287059
e-mail: / North – Derbyshire Wheelchair ServiceMulberry, Clay Cross Hospital
Market Street, Clay Cross
CHESTERFIELD, Derbyshire S45 9NZ
Tel: 01246 252939 Fax: 01246 252973
e-mail:ALL BOXES ARE MANDATORY AND MUST BE FILLED IN. THIS FORM WILL BE RETURNED TO REFERRER IF INSUFFICIENT DATA IS SUPPLIED
Surname: / Male / Female / NHS Number:
Forename(s): / D O B / Title: / Mr / Mrs / Miss / Other:
Preferred Spoken Language: / Ethnic Group:
Address of Wheelchair User: / Address for wheelchair delivery, if different:
Post Code: / e-mail address: / Post Code: / e-mail address:
Telephone Number: / Mobile: / Telephone Number: / Mobile:
GP: / Name of Referrer (If different from GP):
GP Address: / Profession:
Base address:
Telephone Number: / Post Code: / Telephone Number: / Post Code:
Diagnosis / Prognosis / Other relevant medical history which may affect prescription: / Height:
Weight:
Is this referral urgent?: / Yes / No / Hospital discharge? / Yes / No / If hospital discharge please state proposed discharge date:
If referral is urgent state reasons why:
Client Name: / NHS Number:
Does the user need to travel in a vehicle in his / her wheelchair? / Yes / No
Can the user transfer from the wheelchair into a seat in a vehicle? (If No, a head support will be needed) / Yes / No
Does the user have pressure sores? / Yes / No
Has the user had pressure sores in the past? / Yes / No
Has an assessment of the environment where the wheelchair will be used been done? / Yes / No
Are there any known problems with the environment which will affect the use of the wheelchair? / Yes / No
Is the user able to walk at all? / Yes / No
Is this client’s care being funded by NHS Continuing Health Care? / Yes / No
Does the user have Mental Capacity? / Yes / No
If the user does not have Mental Capacity, please identify below who (including contact details), will make the best decision in the interests of the Service User:
Name of Representative: / Address of Representative:
Telephone Number: / Mobile:
e-mail address: / Post Code:
Lap belts are fitted as standard, if not required please give reason why:
Is the wheelchair for: / Indoor / Outdoor / Both / Daily Use / Occasional Use
Method of transfer: / Standing / Sliding / Hoist
How long will the user be seating in the wheelchair? / 8 hours + / 2 – 8 hours / Less than 2 hours
Is a cushion required for the wheelchair? / Standard / Pressure Relieving
(Cushion Referral Form must be attached for non-standard cushions)
Type of cushion used with client and reasons why / Please state waterlow score if known:
If a close technical equivalent is not acceptable, please give reason why:
Type of wheelchair required
Seat and back fold for transporting, removable armrests. Suitable for adults up to 16 stone. Seat size 17” x 17”. Please indicate chair size required below if different:Chair size:
/ Manual Self-propelled / Manual Attendant-propelledManual Self-propelled
Weight of chair 38lbs / 18 Kg /Manual Attendant-propelled
Weight of chair 34lbs / 15 KgIs a Powered Wheelchair required?
/ Yes / No / Position of hand control / Left / RightHas user been assessed for a Powered Wheelchair? / Yes / No
Is a head support required? (See question above regarding transfer into vehicles) / Yes / No
Is a specialist assessment required? (This will be carried out by a Wheelchair Therapist or Rehab Engineer) / Yes / No
Any other comments / summary which may help with prescription:
Is a Voucher Required? / Yes / No / Is the client aware of this referral? / Yes / No
Signature of Referrer: / Designation: / Date:
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