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| New Request Amendment to Existing Request |

|1. PERSON’S INFORMATION |

|Person’s Name |Last Name |ENABLE # |

| |      | |

| |First Name | |

| |      | |

|Title | Mr Mrs Ms Miss Other       |Date of birth:       |

|Address |      |

| |Suburb       Postcode       |

|Phone       |Mobile       |Email       |

|Contact person |Relationship |

|      |Partner Parent Relative Carer Friend |

|Phone       |Mobile       |Email       |

|Diagnosis       |

|Date of surgery: |Date of Discharge:       |

|      |N/A |

|2. EQUIPMENT RECOMMENDATION |

|New Product |Replacement |Product name and Code |Supplier |Supply Allocation |Cost (office use |

| |Product | | | |only) |

| | |Electrolarynx |      | one per person* | |

| | |      | | | |

| | |Indwelling Voice Prosthesis |      | 2/year | |

| | |      | | | |

| | |OR | | | |

| | |Non Indwelling Voice Prosthesis: |      |6/year | |

| | |      | | | |

| | |Trache-oesophageal Dilator: |      | one per person* | |

| | |      | | | |

| | |Gel Cap Insertion Kit: |      | one pack per person* | |

| | |      | | | |

| | |Gel Caps: |      | one pack per person* | |

| | |      | | | |

| | |Cleaning brushes/ flushing device: |      | one pack per person* | |

| | |      | | | |

| | |Tracheostoma/Hands Free Speech Valve Starter |      | one per person* | |

| | |Kit: | | | |

| | |      | | | |

| | |Justification required – see below | | | |

| | |Heat Moisture Exchangers (including foam stoma |      | 365/year** | |

| | |covers): | | | |

| | |      | | | |

| | |Tracheostoma Button: |      | 1/year | |

| | |      | | | |

| | |OR | | | |

| | |Standard Adhesive Seals: |      |365/year** | |

| | |      | | | |

| | |OR | | | |

| | |Non standard Adhesive Seals: |      |180/year** | |

| | |      | | | |

| | |Justification required – see below | | | |

| | |Laryngectomy Tube: |      | 1/year | |

| | |      | | | |

| | |Neck Straps: |      | 12/year | |

| | |      | | | |

|TOTAL COST (Office Use) |$      |

|* These items are supplied once only per person, annual allocations do not apply |

|** This is the standard annual allocation and actual quantity may vary depending on packaging |

|4. EQUIPMENT JUSTIFICATION |

|Has the surgical site stabilized? |

|Yes |

|No |

| |

|Will the equipment be required on a permanent basis (≥ 12 months)? |

|Yes |

|No |

| |

|Is the person able to use the recommended equipment safely and appropriately, including care, maintenance and emergency planning in the event of equipment |

|failure? |

|Yes |

|No |

| |

|Is the person aware of the annual allocation through EnableNSW and has information regarding purchase of additional supplies if required? |

|Yes |

|No |

| |

|Has a trial on all the requested equipment been completed? |

| |

|Yes |

|No |

| |

|If requesting increased annual allocation of indwelling voice prosthesis, and/or provision of non-standard adhesive seals, and/ or a tracheostoma/hands free |

|speech valve, please provide clinical justification to support the request. Please refer to Voice Related Devices and Respiratory Consumables Clinical |

|Criteria. |

|N/A |

|      |

| |

| |

| |

| |

| |

|g) Are any changes anticipated that may impact on this equipment request? |

|(e.g. change to size/type of device) |

|No change anticipated. |

|Yes. If yes, please recommend appropriate supply schedule.       |

|h) Would you like EnableNSW to place the first order of consumables on behalf of the person? |

|Yes Recommended supply in first order: 3 months 6 months |

|No |

|i) Is the person aware of and in agreement with this equipment request? |

|Yes Date agreement received:       |

|No N.B. Application will only be processed with person/carer agreement. |

|i) A copy of the equipment request has been provided to the person. |

|Yes Date       No If no, why?       |

|k) Name and contact details of local speech pathologist (if different to prescriber): |

|      OR |

|See prescriber details below |

|5. DELIVERY INFORMATION |

|a) Who should be notified when the equipment is ready to be delivered? |

|Prescriber Person/contact person |

|Other Provide contact name, relationship, phone, email       |

|b) Delivery address for equipment |

|Person’s home address Other, provide details       |

|c) Delivery Instructions Yes No If yes, details:       |

|6. PRESCRIBER DECLARATION |

|Please provide the name, address and contact details of the prescriber |

| |

|Name:       |

|Service:       |

|Qualification/role:       |

|Phone:       |

|Email:       |

|Address:       |

|Days/hours available:       |

| |

| |

|DECLARATION |

|I declare that I have assessed the person in consultation with an appropriate multidisciplinary team and have the required qualification and level of |

|experience to prescribe this equipment according to the Professional Criteria for Prescribers. |

| |

|Signature: |

|Date:       |

| |

| |

|Supervisor name, name of service, address, phone, email: |Signature of supervisor (if practical): |

|(if required) |      |

|      | |

| | |

| |Qualification:       |

| |Days/Hours available:       |

| |Date:       |

NB: Incomplete forms will delay processing of the application. Please ensure all contact details are provided.

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Name:

Date of Birth:

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