Health Equipment Loan Program Short Term Loan Referral Form -
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1Health Equipment Loan Program
Short Term Loan Referral Form - B.C.
Fax Form To: _____________
Please contact your local Red Cross to confirm equipment availability
Equipped for independence
Client: Last Name:________________________________________ First Name:_________________________________
Address:________________________________________________ City: _______________________ Province: _______
Postal Code: ______________ Phone Number: _____________________ Birthyear (YYYY): ______ Gender: M / F
Height (cm/in): _________ Weight (kg/lb): _________ Personal Health Number _________________________________
Additional Information: ______________________________________________________________________________
Alternate Contact: Name:_____________________________________ Phone Number:__________________________
Adjustable Bath Chair
Frame Walker
Wheelchair
Back
or
No Back
Handgrip-Floor Height: _______inches
Standard
Pediatric
Bath Board
Two Wheels or
No Wheels
Transport
Reclining
Flush
Pediatric
Wide
Seat Width:
Bath Transfer Bench
Glide Brakes
12”
14”
16”
18”
20”
Arm on Right
Arm on Left
Glide Caps/Ski (recommended for
22”
24”
Padded
or
Plastic
carpet)
Seat-to-Floor Height:
Bathtub Safety Rail
Gutter Attachment
Standard (19”)
Hemi (17.5”)
Clamp On
or
Suction
Gutter-Floor Height: ________inches
(All chairs come with footrests)
Left
Right
Both
Elevating Leg Rests
Walker Tray
Right
Left
Both
Other _________________________
Side/Hemi Walker
Foam Cushion (not avail. in all sites)
Handgrip-Floor Height: _______inches
16”x 16”
18” x 16”
18” x 18”
Commode
Raised Toilet Seat
Four Wheeled Walker
Stationary
Pediatric
2”
4”
5”/6”
Seat-Floor Height: ___________inches
Wheeled
Shower
Left Cut Out
Right Cut Out
Handgrip-Floor Height: _______inches
Clamp On
No Clamp
Standard
Wide
5” With Attached Arm Rests
Basket
Tray
Other: _________________________
Elongated toilet seat elevator
Toilet Safety Frame
Other: _________________________
Crutches
Cane
Other
Crutch Height: _____________ Inches
Cane Height: _______________inches
Bed Assist
Axilla
Pediatric
Single
Pair
IV Pole
Forearm
Quad Cane
Bed Cradle
Hand grip Height: ___________inches
Right Side
Left Side
Overbed Table
Gutter Attachment
Small Base
Large Base
Gutter-Floor Height: ________inches
Left
Right
Both
Referring Health Care Professional: Full Name: ___________________________________________________________
Signature: _____________________________________ Phone Number: ______________________________________
Professional Designation (circle one): RN / OT / PT / DR / Other (specify): _______________________________________
Place of Work: ___________________________ Anticipated Length of Loan: 1___ 2___ 3___ 4___ 5___ 6___month(s)
Additional Information:______________________________________________Referral Date: ______- ______ - ______
Rev. April 2014
Month
Day
Year
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Parent category: Medical