Get Dorset Wheelchair Service Referral Form

The Dorset Wheelchair Service Referral Form is essential for individuals needing a wheelchair due to a permanent illness or disability. This guide provides clear, step-by-step instructions on how to complete the form accurately and efficiently online.

Follow the steps to successfully fill out the Dorset Wheelchair Service Referral Form online.

1. Press the ‘Get Form’ button to obtain the Dorset Wheelchair Service Referral Form and open it in the document editor.
2. Begin by filling in your personal details, including your title (Mr, Mrs, Miss, Ms, or Master), surname, forename(s), contact details for a family member or carer who can collect the wheelchair, and address.
3. Provide your telephone number and consent to share information with other agencies regarding your referral and any future assessments and treatments.
4. Fill in your date of birth, NHS number, height, and weight. Clearly indicate your diagnosis and past medical history.
5. Answer the question about whether a self-propelling wheelchair would be contraindicated for your current medical condition by selecting 'Yes' or 'No'.
6. Indicate the type of wheelchair needed by ticking the appropriate box for either attendant-pushed manual, electrically powered indoor, self-propelling manual, or paediatric wheelchair.
7. Summarize your functional disability related to mobility or vision and specify your transfer method.
8. Provide actual body measurements for hip width, depth, knee to heel, and back of bottom to back of knee.
9. Specify how often the wheelchair will be used and for how long during each session.
10. Outline where the wheelchair will primarily be used, whether indoors, outdoors, or both.
11. Indicate if the user will be transported in a vehicle while seated in the wheelchair, and if they have a family member or carer involved in the assessment.
12. Identify any specific indoor usage factors, such as narrow doorways or ramps, and whether an oxygen cylinder or ventilator needs to be accommodated.
13. State if a postural assessment or pressure cushion is required and provide details on any pressure assessments conducted.
14. Provide any additional recommendations regarding models of wheelchairs that might suit your needs.
15. Select between the NHS Wheelchair option or the Voucher Scheme option, and provide any additional information or special considerations needed.
16. Review all sections of the form to ensure completeness and accuracy. Then, finalize by signing the referral and entering the date.
17. Save changes, download, print, or share the completed form as needed.

Complete your Dorset Wheelchair Service Referral Form online today to ensure timely assistance.