Adult Seating Clinic Referral Form

Adult Seating Clinic Referral Form

Hamilton Health Sciences Corporation, General Site

Regional Rehabilitation Centre, 237 Barton St. East, Bldg. 2, Hamilton, ONL8L 2X2

Telephone: (905) 521-2100, Ext. 40806 Fax: (905) 521-2359

THIS PAGE TO BE COMPLETED BY PHYSICIAN

CLIENT NAME______PHONE______

ADDRESS______

______POSTAL CODE______

DATE OF BIRTH ______/______/______HEALTH INSURANCE #______

D M Y

RELEVANT DIAGNOSIS______LENGTH OF TIME ______

PERTINENT MEDICAL INFORMATION (include conditions, allergies & medications which may affect seating prescription)______

______

Current Medical Status______

______

Physician Name (please print): ______

Address: ______Postal Code: ______

Phone: ( )______Fax: ( )______

Physician Signature ______Date ______

Name______Phone ______

Address______

______Postal Code______

Date of Birth ______/______/______Health Card Number ______

D M Y

Version Code______Expiry Date______

Family Physician ______Phone______

Do you have a Community Therapist?  Yes  No

Therapist’s Name ______

Agency ______Phone ______

Has there been any equipment trials recently completed ?  Yes  No

Do you currently have a wheelchair?

/  Yes  No
 Manual Wheelchair / Model
 Power Wheelchair / Model

Do you have special seating in your wheelchair?

/  Yes  No
 Back Support /  Side Supports
 Cushion /  Tray
 Manual tilt/recline /  Power tilt/recline
 Other /  Elevating legs
What are your current wheelchair/seating concerns?
 Pain/Comfort /  Pressure area/Skin breakdown
 Posture/Sitting support /  Mobility
 Condition of current wheelchair
 Other
Comments

What are your goals for clinic involvement?

 New manual wheelchair /  New power wheelchair
 Improved posture /  Improved pressure reduction (manual/power tilt)
 New back support /  New cushion
 Improved mobility
 Other (specify)
Comments
Power of Attorney for Personal Care (if applicable) or Substitute Decision Maker / Name
Relationship Phone
Power of Attorney for Finances (if applicable) / Name
Relationship Phone
Vendor for wheelchairs and seating
(see attached list)
Vendor for custom seating

Consent for Personal Information: I give consent to the Adult Wheelchair and Seating Clinic to collect information about me related to my need for wheelchair and seating/positioning. I understand that this information may be disclosed, as needed, to other members of the care team including, but not limited to, family doctor/referral source, vendor, Ministry of Health Assistive Devices Program (ADP). I understand that the collection and disclosure of information is within the guidelines as established by the Privacy Policy.

______

For use of Email Communication only:

This section disregarded-email communication NOT appropriate 

OR

I agree to allow personal and health information to be sent via email, even though I am aware it may not be secure. Yes  No 

Pertinent information about me may be sent to the following : equipment supplier

Family memberOther:

Signature / Date
If signature is other than client, please identify relationship

This form must be completed in full before an appointment can be made

Return to :

Eleanor Walters, Intake Coordinator

Hamilton Health Sciences

Regional Rehabilitation Centre

237 Barton St. East, Bldg. 2, Hamilton, ON L8L 2X2

Phone: (905) 521-2100 Ext. 40806 FAX: (905) 521-2359

Page 1 of 3

December 7, 2009

Top View