MANUAL WHEELCHAIR - Canadian Red Cross



Request date: FORMTEXT ????? FORMTEXT ????? URGENT FORMCHECKBOX FORMCHECKBOX Short term loan (3 months or less) FORMCHECKBOX Long term loanCHILD INFORMATION FORMCHECKBOX At-Home Program FORMCHECKBOX In–Care FORMCHECKBOX OtherChild Name: FORMTEXT ?????Weight/Height: FORMTEXT ?????Birthdate: FORMTEXT ?????Phone: FORMTEXT ?????Parent/Guardian: FORMTEXT ?????Address: FORMTEXT ?????Ship To: FORMTEXT ?????Professional Designation: FORMTEXT ?????Facility/Organization: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????E-Mail: FORMTEXT ?????EQUIPMENT*************************************************************** (Subject to availability) ********************************************************** FORMCHECKBOX WHEELCHAIR (check all those that apply) Type: FORMCHECKBOX ?folding FORMCHECKBOX rigid FORMCHECKBOX ?tilt in space FORMCHECKBOX recline FORMCHECKBOX transport FORMCHECKBOX hemi-height FORMCHECKBOX power FORMCHECKBOX With transit option other FORMTEXT ????? Seatwidth FORMTEXT ?????depth FORMTEXT ????? seat to floor FORMTEXT ?????back height FORMTEXT ????? Seating: FORMCHECKBOX none FORMCHECKBOX same as spec form Armrests: FORMCHECKBOX ?height adjustable FORMCHECKBOX removable FORMCHECKBOX flip-back FORMCHECKBOX full/desk length other FORMTEXT ?????Hangers: FORMCHECKBOX 60” FORMCHECKBOX 70” FORMCHECKBOX 80” FORMCHECKBOX ?90” FORMCHECKBOX swing away FORMCHECKBOX removable FORMCHECKBOX elevating/smartlegFootrests: FORMCHECKBOX composite FORMCHECKBOX angle adjustable FORMCHECKBOX plateBrakes: FORMCHECKBOX push FORMCHECKBOX pull FORMCHECKBOX extensions FORMCHECKBOX attendantWheels: FORMCHECKBOX 12” FORMCHECKBOX 18” FORMCHECKBOX 20” FORMCHECKBOX ?22”? FORMCHECKBOX ?24”* (subject to STF) FORMCHECKBOX air FORMCHECKBOX polyurethane FORMCHECKBOX solid FORMCHECKBOX mag-rim FORMCHECKBOX spoke rimCasters: FORMCHECKBOX 3” FORMCHECKBOX 4” FORMCHECKBOX 5” FORMCHECKBOX ?6”? FORMCHECKBOX ?7” FORMCHECKBOX ?8”* (subject to STF) FORMCHECKBOX ?air (only available in 8”) FORMCHECKBOX ?aluminium FORMCHECKBOX ?composite rimsOptions:seat belt type FORMTEXT ????? FORMCHECKBOX ?stroller handles FORMCHECKBOX ?ankle huggers FORMCHECKBOX chest strap tray size FORMTEXT ?????other FORMTEXT ?????Powerchair OptionsJoystick: FORMCHECKBOX left FORMCHECKBOX right FORMCHECKBOX center FORMCHECKBOX attendantDrive: FORMCHECKBOX center FORMCHECKBOX rear FORMCHECKBOX frontTilt: FORMCHECKBOX manual FORMCHECKBOX electricScooterType FORMTEXT ?????* (subject to availability) FORMCHECKBOX SEATINGNo seating required, client has custom seating FORMCHECKBOX Cushion: type FORMTEXT ?????size FORMTEXT ?????Backrest:type FORMTEXT ?????size FORMTEXT ?????Head Support: type FORMTEXT ?????size FORMTEXT ?????mounting type FORMTEXT ?????Other Comments: FORMTEXT ????? FORMCHECKBOX TOILETTING AIDSRaised Toilet Seat: FORMCHECKBOX clamp on FORMCHECKBOX bubble FORMCHECKBOX with arms FORMCHECKBOX 2” FORMCHECKBOX 4”Commode: FORMCHECKBOX wheeled FORMCHECKBOX stationary FORMCHECKBOX shower FORMCHECKBOX tilt type FORMTEXT ?????sizesize FORMTEXT ?????” Height of seat from floor FORMTEXT ????? ”* (if available)Toilet Safety Frame: FORMTEXT ?????Standard FORMCHECKBOX Paediatric Toilet Support: size: FORMTEXT ????? ” model: FORMTEXT ????? FORMCHECKBOX height back FORMCHECKBOX low back FORMCHECKBOX padded FORMCHECKBOX unpaddedOther Comments: FORMTEXT ????? FORMCHECKBOX BATHING AIDSTub Transfer Bench: FORMCHECKBOX padded FORMCHECKBOX unpadded FORMCHECKBOX either Arm on FORMCHECKBOX right FORMCHECKBOX leftBath Chair: FORMCHECKBOX back FORMCHECKBOX no backBath Board: FORMCHECKBOX flush FORMCHECKBOX raisedTub Grip:model FORMTEXT ?????Bath Tub Lift:model FORMTEXT ?????Paediatric Bath Seat:model FORMTEXT ?????size FORMTEXT ?????Accessories Needed: FORMTEXT ?????Bath Support: FORMCHECKBOX padded FORMCHECKBOX unpadded FORMCHECKBOX high back FORMCHECKBOX low backsize FORMTEXT ????? Other Comments: FORMTEXT ????? (see over) FORMCHECKBOX TRANSFER AIDSGrab bar(s): describe and mark locationWall Mounted FORMCHECKBOX Floor Mounted FORMCHECKBOX FORMCHECKBOX 12” FORMCHECKBOX 18” FORMCHECKBOX 24” FORMCHECKBOX ?32”Other FORMTEXT ?????location FORMTEXT ?????Handipole:height FORMTEXT ?????location FORMTEXT ????? and do LOJ to MCFD with quote for InstallationTrapeze Bar: FORMCHECKBOX freestanding FORMCHECKBOX to bedPatient Lift: FORMCHECKBOX hydraulic floor FORMCHECKBOX ?power floor FORMCHECKBOX ceilingSling Type FORMTEXT ?????size FORMTEXT ?????” OT must be present for lift delivery Other Comments: FORMTEXT ????? FORMCHECKBOX THERAPY EQUIPMENT Ball: size FORMTEXT ?????type FORMTEXT ????? Peanut: size FORMTEXT ????? Wedge: height FORMTEXT ????? width FORMTEXT ????? rise FORMTEXT ????? Rolls: length FORMTEXT ?????diameter FORMTEXT ????? Mat: length FORMTEXT ?????width FORMTEXT ????? thickness FORMTEXT ????? Other comments FORMTEXT ????? FORMCHECKBOX ENVIRONMENTAL FURNITUREChair: width FORMTEXT ??? ”depth FORMTEXT ??? ”STF FORMTEXT ???? ”type FORMTEXT ????use with seating FORMCHECKBOX ?Y FORMCHECKBOX NCorner Seat:size FORMTEXT ????? ” back height FORMTEXT ???? ”Chair:size FORMTEXT ?????model FORMTEXT ?????Table: width FORMTEXT ??”depth FORMTEXT ???”cut-out FORMTEXT ???”Height Range Required: FORMTEXT ?????Angle Adjustment Required FORMCHECKBOX ?Y FORMCHECKBOX NOther comments: FORMTEXT ????? FORMCHECKBOX STROLLER FORMCHECKBOX ?umbrella style/light weight FORMCHECKBOX jogger FORMCHECKBOX speciality stroller FORMCHECKBOX all-terrain FORMCHECKBOX ?tilt-in-space FORMCHECKBOX reclining model FORMTEXT ?????size FORMTEXT ?????Other Comments FORMTEXT ????? FORMCHECKBOX STANDERSType:? FORMCHECKBOX ?prone FORMCHECKBOX ?supinesize: FORMTEXT ?????Model: FORMTEXT ?????Accessories Required: FORMTEXT ????? FORMTEXT ?????Other Comments : FORMTEXT ????? FORMCHECKBOX WALKING AIDS Walker model: FORMTEXT ????? size: ” Handle height FORMTEXT ????? ” FORMCHECKBOX 2 wheels FORMCHECKBOX 4 wheels FORMCHECKBOX ?seat FORMCHECKBOX ?basket FORMCHECKBOX ?tray FORMCHECKBOX ?hand brakes FORMCHECKBOX ?drag brakes FORMCHECKBOX ?swivel locks FORMCHECKBOX ?antiroll back wheels Gait Trainer model FORMTEXT ?????size FORMTEXT ?????accessories required FORMTEXT ?????Cane height FORMTEXT ?????handle type FORMTEXT ?????type: single point FORMTEXT ?????quad FORMTEXT ????Crutches FORMTEXT ?????height FORMTEXT ?????type FORMTEXT ????? FORMCHECKBOX BEDS/MATTRESSESHospital Bed: FORMCHECKBOX manual FORMCHECKBOX full-electric FORMCHECKBOX semi-electric FORMCHECKBOX trendelenberg FORMCHECKBOX reverse trendelenbergType Of Mattress: size FORMTEXT ?????” FORMCHECKBOX foam mattress FORMCHECKBOX alternating pressure FORMCHECKBOX low air loss FORMCHECKBOX Roho # of sections needed FORMTEXT ????? FORMCHECKBOX Sofflex FORMCHECKBOX levelling sections # of sections needed FORMTEXT ??? FORMCHECKBOX overlay description FORMTEXT ?????Bed Rails: FORMCHECKBOX full FORMCHECKBOX half FORMCHECKBOX bed assist bar FORMCHECKBOX over bed table Other Comments: FORMTEXT ?????Other equipment not listed above: FORMTEXT ?????************************************ (THIS SECTION TO BE COMPLETED BY CMERLS OFFICE) ***********************************Option Available:RCID#: FORMTEXT ?????Description: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX NOT AVAILABLE AT THIS TIME – PLEASE PROCEED WITH DEALER TRIALComments/Special Instruction FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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