DEP Prescription Form (Part A) DEP P-6 Wheeled Mobility Aids Please nominate the equipment this prescription is for: Level 1 General Equipment - DO NOT complete Section 3 2 General or Seating Equipment - COMPLETE ALL SECTIONS Any item that is not on the DEP Approved Equipment List - COMPLETE ALL SECTIONS If completing multiple Prescription Forms for Multiple Equipment Types do not complete section 1B – ATTACH P-C PRESCRIPTION COVERSHEET 1a. Client Details Client ID: Is the applicant an existing DEP client? Yes No Unsure 1b. Further Client Details (Required for single Equipment Type prescription only) CRN (Pension No.): A DEP Application Form is required for all new applicants, and existing clients whose situation has changed or requires confirmation (Special Consideration) Surname: Names: Preferred Phone: : Email: Date of Birth: / / Residential Address: Postal Address (if different): Parent/Guardian (if applicable): Contact Details (if different): Client Diagnosis and Details of Functional Disability: 2. Identification of Need/Clinical Criteria State the clinical criteria that relates to this equipment request: Provide information from the clinical and functional assessment of relevant skills including physical, sensory and cognitive considerations Please ‘check’ as relevant: Manual Wheelchair: Client is unable to walk safely to achieve their functional goals; AND A wheelchair is the client’s primary means of mobility; OR Client is a mixed mobility user; AND Trial Trial
Delivery Instructions DEP to arrange Prescriber to deliver Other, give details: Special instructions (eg. dogs, telephone to delivery, instructions re equipment for replacement, settings etc): Is this prescription for replacement of an existing item? Yes No If Yes, identify a plan to remove/return existing/unsuitable item: DEP to collect item being replaced or Prescriber to arrange return of item being replaced Other, give details: 7. Equipment Review It is the prescribing therapist’s responsibility to ensure correct fitting and client education for DEP equipment on issue. In addition, planned review is recommended within 12 weeks of delivery and use. Please indicate mode of review arranged for equipment following issue: Home visit Telephone Call Client to contact prescriber as needed Other (state details of referral made for follow up, as required): 8. Resources Please attach relevant Resources for this prescription. Refer to Clinical Guidelines. Required Resources for powered wheeled mobility aid attached: Cognitive screen Yes No Vision assessment Yes No Driving assessment Yes No If required, Resources for manual wheeled mobility aid attached Yes No Comment: 9a. Prescriber Details Print and sign to complete Prescriber Name: Approved Prescriber No.: I declare that I am an Approved Prescriber of the appropriate level to prescribe this equipment according to the DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. OR I declare that I have completed this prescription which has been endorsed by an Approved Prescriber of an appropriate level to prescribe this equipment, according to DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers. Signature: Date: / /