Als Society Of Bc Assistive Equipment Prescription Form Page 4
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4ALS Society of BC—Assistive Equipment Prescription Form
Client’s Surname: ________________________
Misc. Equipment
IV Pole
Lift Recline Chair (select size)____________________ width x depth pref.
(select size) SMALL MEDIUM LARGE TALL
Height of client: __________
Weight of client: ___________
Floor to Ceiling Pole __________________ Height of ceiling (Select one) With Arm
Without Arm
Transfer Board _______________ length
Transfer Belt (select size) SMALL MEDIUM LARGE
Portable Ramp _______________ feet in length
Communication Aids
Switches:
Lightwriter
Microlight switch
With Scanner
With Keyguard
Buddy Button
Dynawrite
With Scanner
With Keyguard
Spec switch
VMAX Communication Device (limited number available)
Swifty Adapter
Keyboard Communicator
Touch Mouse Pad (limited number available)
Headmouse (select one) PC Computer
MAC Computer
Voice Amplifier (comes with microphone)
TTY Machine
*The ALS Society of BC does have a very limited number of Eye Gaze Systems, please contact us for further information
Additional Information:
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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
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Parent category: Medical