Fillable Stock Equipment Request Form - Healthshare Enablensw (Page 2 of 2) in pdf

STOCK EQUIPMENT REQUEST FORM

This form can be used to order stock self care and mobility equipment. A current consumer application is also required.

SECTION D: COMPLETE THIS PART (WITH SUPERVISOR AUTHORISATION IF APPLICABLE) FOR: Pressure cushions;

Pressure relieving commode seat; Static air air alternating and air/foam combination overlays; and mattresses

1. Is there a history of pressure areas:

Yes

If Yes, please provide information regarding the stage, duration and date of occurrence of pressure areas:

_______________________________________________________________________________________________________

2. Pressure risk assessment tool

Risk Level

4. Please describe how the features and specifications of the

cushion and/or mattress requested will meet the client’s needs in

the most cost effective way:

3. Please describe ongoing risk of pressure issues once healing

________________________________________________

and/or management strategies have been put in place:

________________________________________________

SECTION E: DELIVERY INFORMATION

1. Delivery address for equipment:

2. Are there special circumstances that require prescriber to be

Client Address

present for delivery?

Other (Specify): ________________________________

Yes

If yes, provide detail:

________________________________________________

_____________________________________

Are there considerations for delivery (i.e. date of discharge,

Notify by email of delivery date

stairs, access etc.)?

Yes

If yes, please specify:

3. Who should be contacted to arrange delivery?

________________________________________________

Name:

Contact Number:

Relationship:

SECTION F

1. Has the client applied for OR is currently receiving assistance from:

A Federal Government Home Care Package (1-4)

Yes

Not known

A Transitional Aged Care Package?

Yes, ending _________

Not known

Additional comments: ____________________________________________________________________________________________

_______________________________________________________________________________________________________________

SECTION G: PRESCRIBER DECLARATION

I confirm that the client/carer is aware of and in agreement with this request.

I understand that all the information that I have supplied on this application is true and correct to the best of my knowledge at the time of assessment.

I understand that I am responsible for advising EnableNSW of any changes to the information provided in this form if I become aware.

I have assessed the client and have the required qualification and level of experience to prescribe this item according to the Professional Criteria for

Prescribers or have included the contact details for my supervisor.

I have read and understand my responsibilities and obligations as provided in the declaration above.

Note: it is an offence under the Crimes Act 1900 to make a false or misleading statement in this application. The maximum penalty is imprisonment for

two years or a fine of $22,000 or both

Prescriber Name:

Signature:

Name of Service:

Qualification:

Address:

Days/Hours Available:

Phone Number:

Email: