Hospital Bed Intake Form
Request date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Age
*
Aprox Height
*
Aprox Weight
*
Electric Hospital Bed
Low Height
Regular Height
Spring
Flat Pan
Height Specification if applicable:
Bed Rails
None
Half
Full
Position:
Mattress
Skin
Pressure relief foam mattress (No skin breakdown or redness)
Air Mattress no Pump (Early stage of skin breakdown)
Alternating Air Mattress Pressure with Pump (More compler and-or multiple areas of skin breakdowns)
True Airloss Mattres with Blower
Bed Mobility
Independent
Caregiver assist with repositioning
Time on Bed
Average (8 - 12 hours)
Moderate (12 - 18 hours)
Significant (18 - 24 hours)
Moisture:
Fall Mat
Fall Prevention Alarm
Bed
Chair
Magnetic Pull Card
Cardless
Other Notes:
Signature
Clear
Submit
Kanata
Hazeldean Mall 17 - 300 Eagleson Road Kanata, ON K2M 1C9
Barrhaven
Medical Centre 205 - 16 Green Street Nepean ON K2J 3R2
Downtown
The Doctor's Building 202 - 267 O'Connor Street Ottawa, ON K2P 1V3
Should be Empty: