UpLyft Customer Intake Form

UpLyft Customer Intake Form
Please fill out this form as completely as possible.
Patient First Name*
M. Initial
Patient Last Name*
MaleFemale
Date of Birth*

MonthDayYear
Date
Street Address*
Apt/Suite Number
City*
State*
Zip Code*
Cell Phone*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email Address*
example@example.com
TRANSFER PROCESS INFORMATION
Self-TransferAssisted Transfer
YesNo
YesNo
Please describe any patient cognitive impairments that may affect the use of UpLyft*? (If none, write N/A)*
Physical Lifting/NoneCloth SlingSit-to-Stand LiftScissor LiftOther (Please State)
YesNo
If yes, what is the hoist or lift brand & model?
*Upper-body mobility, hand dexterity and cognitive acuity are required to operate UpLyft in self-transfer mode.
PATIENT HEALTH INFORMATION
Patient Diagnosis - Please provide as many details as possible.*
Year of Diagnosis
YesNo
Patient Height (Feet)*
Patient Height (Inches)*
Patient Weight (Lbs)*
Patient Waist Size (In)*
Patient Chest Size (In)*
YesNo
Additional Details: Please describe any other prescribed medication(s) or information about the patient’s health that may affect the ability of the patient/user to utilize UpLyft.
*Disclaimer: UpLyft should not be operated in self-transfer mode by an individual who is taking any type of prescription medication that may unexpectedly cause severe drowsiness.
WHEELCHAIR INFORMATION
Wheelchair Brand & Model*
Year Purchased
NewUsed
YesNo
Wheelchair seat width between armrests (In)*
Wheelchair height between seat and armrests (In)*
HOME & BEDROOM INFORMATION
Standard (80”H x 36”W)Other
Bedroom Ceiling Height (In)*
Height of Patient’s Bed - Including Mattress (In)*
How much open space is available on each side of the patient's bed?
Left Side (In)*
Right Side (In)*
Front (In)*
FINAL ADDITIONAL DETAILS
Is there any other information about the patient’s wheelchair, hoist/lift or home environment that UpLyft should be aware of?
DECLARATION
I have completed this questionnaire to the best of my knowledge and commit to advising UpLyft if there are any changes to the above information. I understand that upper-body mobility, hand dexterity, cognitive acuity and alertness are required to operate UpLyft in self-transfer mode. I understand that UpLyft shall not be held responsible for any damages that may occur should a patient decide to operate UpLyft in self-transfer mode without exhibiting the above qualifications.
Signature*

Clear
Patient/Caregiver Full Name*
Date*

MonthDayYear
Date
For any questions or comments when filling out this form, please contact us at sales@uplyfthealth.com or 1-833-753-0666.
Should be Empty:

UpLyft Customer Intake Form

TRANSFER PROCESS INFORMATION

PATIENT HEALTH INFORMATION

WHEELCHAIR INFORMATION

HOME & BEDROOM INFORMATION

FINAL ADDITIONAL DETAILS

DECLARATION