Request date: URGENT Short term loan (3 months or less) Long term loan INFORMATION At-Home Program In–Care Other Child Name: Weight/Height: Birthdate: Phone: Parent/Guardian: Address: Ship To: Professional Designation: Facility/Organization: Phone: Fax: E-Mail: EQUIPMENT *************************************************************** (Subject to availability) ********************************************************** WHEELCHAIR (check all those that apply) Type: rigid in space recline transport hemi-height power With transit option other Seat width seat to floor back height Seating: none same as spec form Armrests: adjustable removable flip-back full/desk length other Hangers: 60” 70” 80” swing away removable elevating/smartleg Footrests: composite adjustable plate Brakes: push pull extensions attendant Wheels: 12” 18” 20” * (subject to STF) air polyurethane solid mag-rim spoke rim Casters: 3” 4” 5” * (subject to STF) (only available in 8”) rims Options: seat belt type handles huggers chest strap tray size other Powerchair Options Joystick: left right center attendant Drive: center rear front Tilt: manual electric Scooter Type * (subject to availability) SEATING No seating required, client has custom seating Cushion: type size Backrest: type size Head Support: type size mounting type Comments: TOILETTING AIDS Raised Toilet Seat: clamp on bubble with arms 2” 4” Commode: wheeled stationary shower tilt type size size ” Height of seat from ” * (if available) Toilet Safety Frame: Standard Paediatric Toilet Support: size: ” model: height back low back padded unpadded Other Comments: BATHING AIDS Tub Transfer Bench: padded unpadded either Arm on right left Bath Chair: back no back Bath Board: flush raised Tub Grip: model Bath Tub Lift: Paediatric Bath Seat: model size
Accessories Needed: Bath Support: padded unpadded high back low back size Other Comments: (see over) TRANSFER AIDS Grab bar(s): describe and mark location Wall Mounted Floor Mounted 12” 18” 24” Other location Handipole:height location and do LOJ to MCFD with quote for Installation Trapeze Bar: freestanding to bed Patient Lift: hydraulic floor floor ceiling Type size ” OT must be present for lift delivery Comments: THERAPY EQUIPMENT Ball: size type Peanut: size Wedge: height width rise Rolls: length diameter Mat: length width thickness Other comments ENVIRONMENTAL FURNITURE width ” depth ” STF ” type use with seating N Corner Seat: size ” back height ” size Table: width ” depth ” cut-out ” Height Range Required: Angle Adjustment Required N Other comments: STROLLER style/light weight jogger speciality stroller all-terrain reclining model size Other Comments STANDERS size: Accessories Required: Other Comments : WALKING AIDS Walker size: ” Handle height ” 2 wheels 4 wheels brakes brakes locks back wheels Gait Trainer model size accessories required Cane height handle type type: single point quad Crutches height type BEDS/MATTRESSES Hospital Bed: manual full-electric semi-electric trendelenberg reverse trendelenberg Type Of Mattress: size ” foam mattress alternating pressure low air loss Roho # of sections needed Sofflex levelling sections # of sections needed overlay description Bed Rails: full half bed assist bar over bed table Other Comments: Other equipment not listed above: ************************************ (THIS SECTION TO BE COMPLETED BY CMERLS OFFICE) *********************************** Option Available: RCID#: Description: NOT AVAILABLE AT THIS TIME – PLEASE PROCEED WITH DEALER TRIAL Comments/Special Instruction