ALS Society Equipment Form 2024

Equipment Loan Program - Request For Equipment

Please note, there are two spaces to provide further details and information if needed.
This Equipment Request is Urgent

Yes
Client
Date of Request

MonthDayYear
Date
Height
Weight
ALS Client Services Coordinator
Requested by*
Therapist Phone*
Therapist Email*
example@example.com
PLEASE MAKE ARRANGEMENTS TO DEMONSTRATE SAFE USE OF EQUIPMENT BEFORE THE EQUIPMENT IS USED
Do you wish to be present at the time of delivery?

yesno
Therapist confirms application has been made to AADL for large equipment.

YesNo
Does the client have extended health benefits

yesno
Request for Rebate Program

BidetEasy Lift Chair
Comments/Additional Information
The ALS Society of Alberta will be in touch within 2 business days to address your request
Bathroom Aids

Bath SeatBath Seat With BackBath LiftBath Lift With ReclineTub Transfer Bench - Arm on RightTub Transfer Bench - Arm on LeftToilet Safety FrameTub Safety RailRaised Toilet Seat - Add inches belowRaised Toilet Seat With armsRaised Toilet Seat RoundRaised Toilet Seat OvalCommode -stationaryCommode - wheeledCommode - TiltOther
Raised Toilet Seat: Inches
Beds & Accessories

Full Electric Hospital BedMattressOverlay - spencoOverlay - sheepskinOverlay - RohoOverlay - GelBed Rail - M-RailOverbed TableSheepskin - add size/type belowBed Wedge - 7"Bed Wedge - 10"Bed Wedge - 12"Other
Sheepskin Size/Type
Computer & Communication Needs

LaptopiPadAndroid TabletSoftware: add any details belowAlternative Mouse: add any details belowSpeakersSwitch: add type belowCall Bell/Door ChimeAdaptable Call BellWireless Voice AmplifierWired Voice AmplifierMicrophone - HeadsetMicrophone - CollarMicrophone - LapelMicrophone - NeckLaser PointerOther
Software Details
Alternative Mouse Details:
Switch Type
Adaptive Phone Type
Lifts

Please allow extra time for site assessments. Only straight run stair lifts provided.
Stair Lift Type Location
Porch Lift Type Location
Ramp up to 12' Type Length
Threshold Ramp Add Height/Width
Ceiling Track Assessment Type Location
Freestanding Track Type Location
Lifter unit - Ceiling (short term loan only)Lifter unit - Floor (short term loan only)Lifter unit - Sit to Stand (short term loan only)
Slings - Short Term Loan Only

SmallMediumLarge
What type of sling? Please indicate whether you require Universal; Toileting; Full Body; Sit to Stand; or other option
Mobility/Transfer Aids
Mobility/Transfer Aids

Scooter (Lightweight/Transportable models provided only)Superpole - add location and height belowSuperpole with super bar - add location and height belowWalker: 2 wheeled - add details belowWalker: 4 wheeled - add details belowTransfer SheetTransfer BeltOther
Superpole Install Location
Superpole Ceiling Height

Less than or equal to 8'More than 8'
Walker Seat and Handle Height
Please complete Seating Specifications Below for Wheelchair Requests*
Wheelchair Requests

17" Transporter Chair19" Transporter ChairManual WheelchairTilt-in-Space Manual WheelchairPower Wheelchair: please check all that apply, and we will do our best to fulfill what you have requested.TiltReclineElevating Leg RestSeat ElevationDrive Preference: MidDrive Preference: RearControls: leftControls: rightControls: attendantAlternative Controls (add details below)Wheelchair cushion (specify type below)
Alternative Controls
Wheelchair Cushion
*Please note we have limited stock of Standard Manual

Wheelchairs (Short Term Loan Only)*
Seating Specifications
Width x Depth
Seat to Floor
Seat to Top of Head
Back Height
Front Rigging/Legrests
Armrest Type
Tray
Other equipment/comments
Please click "Submit" - your submission will be forwarded to the Client Service Coordinator indicated above.
Should be Empty:

Lifts

Mobility/Transfer Aids

Please complete Seating Specifications Below for Wheelchair Requests*

Seating Specifications