Als Society Of Bc Assistive Equipment Prescription Form (Page 3 of 4) in pdf

Als Society Of Bc Assistive Equipment Prescription Form Page 3

ALS Society of BC—Assistive Equipment Prescription Form

Client’s Surname: ________________________

Bathroom Aids



Bath Seat (select one) With Back

Without Back



Raised toilet seat (select one) With Arms Without Arms

_____ inches (height)

*please note: we do not carry elongated Raised Toilet Seats



Toilet Safety Frame



Commode (select one) Stationary

Wheeled

Drop arm needed? Yes No



Wheeled Shower Commode

Tilt needed? Yes

No



Tub Transfer Bench (select one) Arm on Right

Arm on Left



Tub Grip



Electric Bath Lift

Lifts



Portable patient lift (select one) Regular Compact



2 post lift system



Sit to Stand Lift (limited number available)

Sling (1 sling per patient member)

 Hammock Sling (select size) SMALL MEDIUM LARGE

Universal/Quick fit Sling (select size) SMALL MEDIUM LARGE

Beds & Accessories



Hospital Bed (select one)  Full Rails

 1/2 Rails



Nyaac portable bed rail



Regular LTC 3000/4000 mattress with sensus



Specific Mattress type required

*OT will be contacted for specific mattress information



Roho mattress section _______ quantity (max. 3)



Leveling pads ______ quantity



Overbed Table

1233—13351 Commerce Parkway, Richmond BC PH 604-278-2257 OR 1-800-708-3228 FAX 604-278-4257

Email: equipmentloan@alsbc.ca Website:

CHARITABLE REGISTRATION # 10670 8985 RR0001

Page 3 of 4

Als Society Of Bc Assistive Equipment Prescription Form Page 3

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