ILC AES Referral Information – Electric beds

Thank you for providing the following information. This general information will allow our team to prepare for your appointment and ensure the relevant equipment is available.
Client Information
First Name*: / Last Name*:
Date of Birth*: / Age
Suburb*: / Street Address:
Phone Number*: / Email:
Country of Birth: / Main Language Spoken:
Funding / Eligibility (tick or circle all applicable):
☐Disability Support Pension / ☐ Aged Care Pension / ☐ Health Care Card / ☐ DVA Card
☐NDIS / ☐WANDIS / ☐ Better Start / ☐ Helping Children with Autism / ☐ Enhanced Primary Care
☐Home and Community Care (HACC) / ☐Commonwealth Home Care Package /
☐ Private Health Insurance
Other:
Primary Diagnosis:
Other Relevant Medical History:
Weight*: / Height*:
Mobility: eg. method of mobility, equipment used, level of assistance required
Transfer Ability:eg. method of transfers and level of assistance required
Communication: eg. difficulties with hearing, vision, speech, devices used, level of assistance required
Carer / Parent / Alternate Details (please circle)
First Name: / Last Name:
Relationship to client:
Phone Number: / Email:
Primary Therapist / School / Support Agency Details (please circle)
First Name: / Last Name:
Position: / Organisation:
Phone Number: / Email:
Reason for Referral
Summary of why the referral has been sent. What equipment category / type do you wish to view?
What are the difficulties the client is having? What are their strengths / abilities?
Include any relevant details relating to the person, their carers and environment.
Current Equipment Used
What relevant equipment is the client currently using? Why is this not sufficient?
Features Required in New Equipment
Please list any specific equipment features required. Please note: not all features are necessarily compatible / possible in one wheelchair. Suppliers often only have one demo item available, which may not be in the required size or features, even if available when scripting / ordering the equipment.
Size of bed: (please circle or tick) ☐single / ☐ king single / ☐ long single / ☐ double / ☐ queen / ☐ split queen / ☐ king / ☐ split king /
Is electric height adjustment required: / Is electric head raise required:
Is electric leg raise required: / Is manual/electric knee break required:
Is Trendelenburg function required? / Is under-bed clearance for hoist required?
Please circle if any of the following features are required: ☐ Folding / ☐ Able to dismantle
Other: are there any other features required such as full/halfbed rails, collapsible side rails, overhead pole
If you also want to look at mattresses:
Pressure risk: eg. as per assessment findings, Waterlow / Braden Scale score
Type of mattress: eg. foam, latex, inner spring, static air, combination, alternating air
Other: are there any other mattress features required
Specific Equipment Requests
Please list any specific equipment items you wish to view. Please note: although we will endeavour to obtain these for the appointment, there is no guarantee of availability. We can advise you of availability.
Additional Appointment Requests:
Preferred date / day / time*:
Who will be attending appointment?:
Referrer Details
First Name*: / Last Name*:
Relationship to client*: / Best contact*
Date of Referral*:

Page 1 of 3