ILC AES Referral Information – Power Wheelchairs

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 wheelchair.
Wheelchair Seat Width: / Wheelchair Seat Depth:
Seat to Footrest Height: / Backrest Height:
Drive Type: eg.mid, front, rear / Arm support type:
Leg rest type: / Foot plate type:
Back support type: / Cushion type:
Control location: / Additional control requirements:
Please circle if any of the following power features are required:
Posterior Tilt / Anterior Tilt / Recline / Elevating Leg rests / Seat Height Adjustment / Standing Function
Other: are there any other features required eg. headrest, tray, harnesses, push handles, attendant controls,
Will the wheelchair be used to transport a user in a vehicle? Ie. Does you want it to be “crash tested”?
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*:

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