Brighton Wheelchair Services

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					Brighton Wheelchair Services
Sussex Rehabilitation Centre (Brighton)
Brighton General Hospital
Elm Grove, Brighton BN2 3EX
Tel: (01273) 674391 Fax: (01273) 605063

                                          REFERRAL FOR WHEELCHAIR
                    All sections of this form must be filled in for a wheelchair to be issued
               Please note the wheelchair service does not provide short-term loan wheelchairs

Client’s name: MR/MRS/MISS/MS                                                             Nhs no

Post code                                      Tel
Delivery address (if diff from above)

Post code                               Tel
Are either of these addresses a residential home       or a nursing home                   ?
Has the client given consent for this referral to be made? YES        NO

Date of Birth                         Height                             Weight
Complete Medical History and Medication (please include both physical and mental health aspects)

Functional Ability

GP Name (print initials and                                                      Signature (unless
surname):                                                                        e-copy)
Surgery address

Post code                                                        Tel

Name of primary carer
Relationship if any

                                 British, Irish, Other white, White & Black Caribbean, White & Black African, White Asian, Other mixed,
                                 Indian, Pakistani, Bangladeshi, Other Asian, Caribbean, African, other, Chinese, Other, Not stated

Is the client already in possession of a wheelchair issued by the NHS?                     YES       NO

How often will the wheelchair be used?
   Everyday       How many hours?                                   Once a week or less               More than once a week

Where will the wheelchair be used?

What type of wheelchair is required?                     Child’s buggy
  Manual wheelchair pushed by attendant                  Powered indoors wheelchair controlled by client
  Manual wheelchair pushed by client (large wheels)      Powered indoors & outdoors controlled by client
NB User operated out-door powered scooters are not supplied by the wheelchair service
Will the client sit in the wheelchair during transport?        YES      NO
If no, will the wheelchair be put in the vehicle when the client is transported?    YES   NO

Is the client at risk of / have a history of / have any existing pressure areas?    YES   NO
Please give details if applicable (location / grade)

Postural need: Does the client require any support to sit up?                 YES   NO
Please give details if applicable

Cushion: Please note all wheelchairs are supplied with a 50mm (2”) foam cushion as standard. The
Occupational Therapist will deem whether it is necessary for an alternative cushion to be provided based on
the information included in this referral form and further assessment if necessary

Please return form to address on front page or email to

Referral for Wheelchair Assessment – 02/07/2008