Children’s Medical Equipment Recycling & Loan Service

Canadian Red Cross – Lower Mainland Region

3400 Lake City Way, Burnaby, BC V5A 4Y2

Tel: 604-709-6685Fax: 604-709-6688

Request for Equipment

Request date: URGENT / Short term loan(3 months or less) Long term loan
CHILD 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)**********************************************************

Non-biomed Request for Equipment

December 2012

WHEELCHAIR(check all those that apply)
Type:folding rigid
tilt in space recline
transport hemi-height
power With transit option
other
Seatwidth / depth
seat to floor / back height
Seating: none same as spec form
Armrests:height adjustable removable
flip-back full/desk length
other
Hangers:60” 70” 80” 90”
swing away removable
elevating/smartleg
Footrests: composite angle adjustable
plate
Brakes: pushpull
extensions attendant
Wheels:12” 18” 20” 22”24”
* (subject to STF)
air polyurethane solid
mag-rim spoke rim
Casters:3” 4” 5” 6”7” 8”
* (subject to STF)
air (only available in 8”)
aluminiumcomposite rims
Options:seat belt type
stroller handlesankle huggers
chest strap tray size
other
Powerchair Options
Joystick: left rightcenter attendant
Drive:center rear front
Tilt: manual electric
ScooterType
* (subject to availability)
SEATING
No seating required, client has custom seating
Cushion: type
size
Backrest:type
size
Head Support:type
size
mounting type
Other Comments:
TOILETTING AIDS
Raised Toilet Seat:clamp onbubble
with arms2”4”
Commode: wheeled stationary
shower tilt
type / sizesize / ”
Height of seat from floor / ”
* (if available)
Toilet Safety Frame: / Standard
Paediatric Toilet Support: size: / ”
model:
height back lowback padded unpadded
Other Comments:
BATHING AIDS
Tub Transfer Bench:paddedunpadded
either
Arm on right left
Bath Chair:back no back
Bath Board: flush raised
Tub Grip:model
Bath Tub Lift:model
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 MountedFloor Mounted
12” 18” 24” 32”
Other / location
Handipole:height / location
and do LOJ to MCFD with quote for Installation
Trapeze Bar: freestanding to bed
Patient Lift: hydraulic floor power floor
ceiling
Sling Type / size / ”
OT must be present for lift delivery
Other Comments:
THERAPY EQUIPMENT
Ball: size / type
Peanut: size
Wedge:height / width
rise
Rolls: length / diameter
Mat: length / width
thickness
Othercomments
ENVIRONMENTAL FURNITURE
Chair: width / ” / depth / ” / STF / ”
type / use with seating Y N
Corner Seat:size / ” / back height / ”
Chair:size / model
Table: width / ” / depth / ” / cut-out / ”
Height Range Required:
Angle Adjustment RequiredY N
Other comments:
STROLLER
umbrella style/light weight jogger
speciality stroller all-terrain
tilt-in-space reclining
model / size
Other Comments
STANDERS
Type:pronesupinesize:
Model:
Accessories Required:
Other Comments :
WALKING AIDS
Walker model: / size: ”
Handle height / ”
2 wheels 4 wheels
seat basket tray
hand brakesdrag brakes
swivel locksantiroll back wheels
Gait Trainer
model / size
accessories required
Caneheight / 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:

Non-biomed Request for Equipment

December 2012

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

Non-biomed Request for Equipment

December 2012