Stock Equipment Request Form - Healthshare Enablensw
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2STOCK EQUIPMENT REQUEST FORM
This form can be used to order stock self care and mobility equipment. A current consumer application is also required.
SECTION A: CLIENT DETAILS
Title:
Client First Name:
Client Last Name:
Date of Birth:
EnableNSW Number (if known):
Address:
Postcode:
Phone Number:
Mobile Number:
Diagnosis:
______________________________________________________________________________
(Mandatory Field)
Contact Person (if not client):
Contact Ph. Number:
Relationship:
SECTION B: STOCK ITEMS REQUESTED
Part Number*
Equipment Description
Qty
Replacement item
Pick up old
(tick yes or no)
equipment?
(Mandatory Field)
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Additional clinical
_____________________________________________________________________________________________
justification:
_____________________________________________________________________________________________
SECTION C: IDENTIFICATION OF NEED/CLINICAL CRITERIA FOR EQUIPMENT
1. Client centered goals that relate to this request for equipment
2. The equipment is primarily required for:
Carer/Client will be safe/independent with:
To reduce immediate risk of injury to the client and/or
Self care tasks
caregiver
Mobility
For daily use at home
Transfers: Is the requested hoist only being used for
For community use
transfers post fall?
Yes
No
Other
Briefly explain: ___________________________________
Briefly explain: ___________________________________
________________________________________________
________________________________________________
Pressure care prevention – Please also complete Section D
3. Please provide the weight of the client:
Other - Briefly explain:
________________________________________________
________________________________________________
________________________________________________
Is client’s weight within the safe working load of equipment being
Within:
requested:
The home
Yes
The community
No
Other - Briefly explain:
________________________________________________
4. Is the use of this equipment compatible with the client’s
________________________________________________
environment:
How often will this equipment be used:
Yes
Continually/Multiple times a day
No
Once a day
Provide details:
1 – 2 Week
________________________________________________
Less than once a week
________________________________________________
________________________________________________
Briefly explain: _____________________________________
________________________________________________
________________________________________________
Stock Equipment Request Form v7 2014.02.26
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