Wheelchair Intake & Build Information

Wheelchair Intake & Build Information
Select Location
Requested Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Phone Number*
Phone Number
Email*
example@example.com
Aprox Height*
Aprox Weight*
Gender
Aprox Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Contact: (if necessary):
Full Name

First NameLast Name
Phone Number
Phone Number
Email
example@example.com
Therapist Contact:
Full Name

First NameLast Name
Phone Number
Phone Number
Email
example@example.com
Request Type:
Request

Rental WheelchairNew WheelchairOther
Category

Cat 1 - Folding Basic WheelchairCat 2 or 3 - Folding Rehab Manual WheelchairCat 4 - Rigid Manual wheelchairCat 5 Tilt Manual WheelchairPower Wheelchair
Wheelchair Measurements (Optional):
A. Chair Width
B. Chair Depth
C. Seat to Floor Finished
D. Foot Rest length
E. Back Rest Height
F. Back Rest Width
G. Head Rest Height
Components:
Cushion AirFoamHybridGel
Backrest ActiveLateral SupportKyphosis
Extra Cushion Cover
Solid Seat Insert
Lumbar Pads
4-point seat belt
Soft Roll Casters
Lap TrayLHSRHSFull
Elevating Leg RestLHSRHS
Head Rest
Calf Panel
Foot Box
Other:
Other notes:
Incontinence:
Foot Properler:
Kanata

Hazeldean Mall 17 - 300 Eagleson Road Kanata, ON K2M 1C9
Barrhaven

Medical Centre205 - 16 Green StreetNepean ON K2J 3R2
Downtown

The Doctor's Building202 - 267 O'Connor Street Ottawa, ON K2P 1V3
Should be Empty: