Liverpool Community Equipment Service

Equipment Referral Form

Please Fax back to the Equipment Service on 0151 282 5180

Referrer
Order Number / Pin Number
Name / Job Title
Telephone / Email
Base / Referral Date
Assessment Date / Delivery or Collection
Equipment Delivery
NHS No / Title
Forenames / Surname
Address / Postcode
DOB / Age
Home Tel / Work Tel
Mobile Tel / Minicom No
Advocate Req / Advocate Name and Number
British Sign Lang / Interpreter Req
Gender / Ethnicity
Nationality / First Language
Weight / Height
Diagnosis Code / If End of Life
Priority for Delivery / Risk Assessment
Date of Risk Assessment / Risk Assessment details
Accommodation
Lives Alone / If No, Who With
Key holder / Key holder Name Number
Accom Type / If Flat, What Floor
Access Difficulties / If Yes, Details
Emergency Contact / Next of Kin
Emergency Contact Forename / Emergency Contact Family Name
Emergency Contact Tel
GP Involvement
GP Practice / GP Telephone
Other Information
Is This An Exchange / Other Information
Additional Instructions
Equipment Request
Pressure Care Mattress Request
Diagnosis
Time In Bed / Time In Chair
Weight / Ability to Change Position
Pressure Ulcer present / Location Of Ulcer
Grade Of Ulcer / Is Pressure Care Already Used
If Yes Give Details
Waterlow Score / Mattress Level
If Other, please specify
Waterlow Score Card
BMI / Sex
Age Range / Skin Type
Continence / Mobility
Has Lost Weight? / Weight Loss
Eating Poorly / Tissue Malnutrition
Neurological Deficit / Major Surgery / Trauma
Medication
Profiling Bed Request
Diagnosis
Time In Bed / Time In Chair
Weight / Ability to Change Position
Why Is Own Bed Unsuitable
Tried Other Beds / adapts
If Yes, Why Unsuitable
Is knee-break essential? / Rails required
Failure to correctly complete every required field within this referral will result in the referral being rejected.
This will cause a delay in the delivery of prescribed equipment and is the responsibility of the referrer and not the Community Equipment Service.
Rejection of referrals will be notified via email and so it is recommended that these are checked regularly.
I have read the above and completed all required fields on this referral
Signature: Date:

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