IMPORTANT

This referral is for a medical device and must be completed in full to confirm that the intended recipient meets the service criteria for supply and will agree to the Dorset Wheelchair Service conditions of loan.

Dorset Wheelchair Service will accept first referrals from individuals (self-referrals). If you are a registered healthcare professional (HCP) and would like to refer someone, please go to our website for more information: HealthCare Professionals

This referral form must only be completed when a client needs a wheelchair because of a PERMANENT illness or disability affecting their mobility.

Any information you provide in the Self-Referral will be handled in accordance with the Trust's Privacy Notice

Personal Wheelchair Budget

The Personal Wheelchair Budget (similar to the previous Voucher Scheme) was introduced to give greater choice to those who do not wish to have the standard NHS provision and involves a financial contribution from either yourself or other funding bodies such as Social Services, Education and charities.

Further information is available on request or through our website. Conditions apply.

Patient Details
Alternative Contact Details
Do you have an alternative contact: *
Contact's name:
Contact's relationship to you:
Do they have Lasting Power of Attorney:
Do they live with you:
Contact's contact number:
Contact's email address:
Accessibility
Do you require an interpreter?
Which language do you need assistance for?
Do you have any other communication needs, e.g. sight or hearing?
What do you require help with?
Can you participate in a video assessment as part of the referral? *
Existing Conditions
Which GP surgery are you registered with? *
Primary diagnosis? *
Please specify any current, or previous, medical conditions, including allergies, you have been treated for.
Please list all medications currently being taken
Does your medication cause drowsiness? *
Have you ever had epilepsy? If yes, please advise on frequency of seizures, duration, night/day, date of last seizure
Do you experience other loss of consciousness, not related to epilepsy? *
Do you have any pressure areas of concern on your body? Please state location and if known, the grade of pressure area damage
Have you had any previous skin breakdown (exact location / grade if known / description)
Do you have a life limiting condition with less than six months to live? *
How can we help
What type of equipment is the referral for? *



Reason for making this referral *
How often will you use the wheelchair? *


How long will you be seated in the wheelchair during the day? *



Where will you use the wheelchair? Tick all that apply. *



Do you have a currently have a wheelchair? *
Your current wheelchair?
Your current wheelchair's seating system?
Do you have your own, or access to, transport? *
What type of transport do you have? *



Will you be seated in the wheelchair in transport? *
Would you like a family member/carer to be present at your assessment? *
Is there any reason you would be unable to attend the Wheelchair Clinic? *

If there are difficulties with transport, you may be able to get help to attend clinic from Patient Transport Advice Centre (PTAC) – 01278 272 457

Mobility
What is your level of mobility? *



Have you had any recent falls inside your home? *
Have you been referred to a ‘Falls Clinic’? *
How do you transfer between surfaces? (e.g. bed / toilet / chair) *




How is your sitting balance? *






Your height *
Your weight *
Other Health Professionals Involved in your care
Community OT
Community Physio
Learning Disability Service
Social Care
School Staff
Speech & Language
District Nursing
Tissue Viability
Referral
Referred By *