Tower Hamlets Wheelchair Service Self Referral Form

Tower Hamlets Wheelchair Service Self Referral Form

This self-referral form is for manual wheelchairs only. If you want to be referred for a powered wheelchair, a referral has to be completed by an occupational therapist, physiotherapist or social worker. Powered wheelchairs requested via this form will be rejected.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemaleOther
Ethnicity*
Preferred Language*
Is an interpreter required?*

YesNo
NHS Number*
Current Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Email*
example@example.com
Phone number*
Alternative phone number
Height and Weight

Please provide your height and weight (we need this information to provide you with a wheelchair that fits)
Height*
CM or Feet and Inches
Weight*
KG or Stone
Referrer Information
Are you completing this form for yourself or someone else?*

MyselfSomeone else
Name of person completing the form*

First NameLast Name
Telephone number of person completing the form*
Relationship to client*
Do you have the client's consent to complete this form?*

YesNo
Next of Kin
Name of next of Kin*

First NameLast Name
Telephone number of next of kin*
GP Details
Name and contact details of GP*

Medical Information
Please list your current disability/diagnosis and relevant past medical history:*
Please note: If you suffer from any heart or lung problems you may find it difficult to push yourself in a wheelchair. If you have any concerns speak to a health care professional.
Do you have an Occupational Therapist/Physiotherapist or other health care professional involved?*

YesNo
Name and contact details of Occupational Therapist/Physiotherapist*
Do you currently have a wheelchair?*

YesNo
Make and model of wheelchair (if known)
Was the wheelchair provided by the NHS?*

YesNo

Last Few Questions
Wheelchair Service are now offering Personal Wheelchair Budgets (PWB’s)

This enables you to make a choice of having the NHS (Notional) wheelchair or another wheelchair (Third Party). What this means is, if you are eligible for a wheelchair from the NHS then you can choose to have the NHS wheelchair with maintenance and repair covered, or choose to have the budget of the NHS wheelchair with an added amount for maintenance and repair to purchase something privately. This budget would last for 5 years.

Please see the attached leaflet for more details.

The wheelchair the NHS will issue is a Breezy Basix or similar.

The budget for the Third Party option would be based on the Action 2NG.

Please indicate whether you would like to continue with the NHS wheelchair or discuss the PWB further with a member of the Wheelchair Service.
I would like to have*

NHS (Notional) wheelchair provisionDiscuss other PWB options
If you are happy to proceed with the NHS (Notional) option, direct delivery may be arranged. Please indicate if you are happy for our repair and maintenance service to contact you to arrange delivery

Yes
We sometimes need to contact your GP or other health care professionals to help us provide you with the most suitable equipment. We will only do this if we don’t have enough information to supply a wheelchair. Do you give us permission to contact other health care professionals?*

YesNo
Please note that depending on the information you have provided, a therapist may determine that further assessment is required before a suitable option can be determined for you. In this case, you will be placed on the waiting list for a clinic assessment
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Tower Hamlets Wheelchair Service Self Referral Form

Height and Weight

Referrer Information

Next of Kin

GP Details

Medical Information

Desired Outcome of Assessment/Provision

Functional Information

Social and Environmental Information

Last Few Questions