Medical Request Form For A Wheelchair Accessible Unit And/or Additional Bedroom
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1
2Complete and return this form by mail or in person:
Halton Access to Community Housing (HATCH)
Employment Housing and Social Services
th
690 Dorval Dr, 7
Floor
Oakville, ON L6K 3X9
MEDICAL REQUEST FORM FOR A WHEELCHAIR ACCESSIBLE UNIT
AND/OR ADDITIONAL BEDROOM
Patient Name: _________________________________________
Patient Address: ____________________________________________________________
Patient’s disability or medical condition:
(Please Print)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Wheelchair Accessible (WCA) Unit Request
(Do not complete the section below if the patient (s) is only requesting an additional bedroom)
Please note that the use of a scooter, walker or wheelchair does not automatically qualify a
patient for a WCA modified unit.
Modified units vary among Housing Providers (HP) and therefore have varying degrees of
modifications. Patients may contact HATCH to discuss property selections once this form is
returned to HATCH for processing.
Please answer the following questions:
1. Is the patient in a wheelchair?
Full-time
Part-time
Not-at-all
2. Is the Patient’s diagnosis
Permanent
Temporary
3. If the Patient’s diagnosis is temporary what is the expected duration? _________
What equipment does the patient use?
(Please Print)
#
#
Type of Equipment used
Type of Equipment used
Physician’s Release
I hereby certify that this information
Space for physician’s stamp
represents my best professional judgment
and is true and correct to the best of my
knowledge.
_______________________
_________________
Physician’s Name (Printed)
Telephone
____________________
_________________
Physician’s Signature
Date
V 1.02.2012
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