Referral for Equipment

Referral for Equipment
Name*

First NameLast Name
Date of Birth *

DayMonthYear
DoB
Email*
example@example.com
Address*

Street Address

Street Address Line 2

PostcodeState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number. (Mobile)
Are you filling out this referral on behalf of someone else?

YesNo
If you have answered yes, please provide your name and email address *

First NameLast Name
Email address
example@example.com
If you are requesting a wheelchair or mobility scooter, please provide the following measurements:

HeightWeight
Which equipment are you applying for and why:*
Please also enter the correct equipment code
Are you on a means tested benefits or low income?*

YesNo
(Proof will be required)
Do you have a Long Term Health condition that impacts your life?*

YesNo
DISCLAIMER AND ACKNOWLEDGMENT:
Please be advised that any equipment obtained from Chronically Marvellous is provided “as is"without any warranty. We do not assume responsibility for any damages that may occur to the equipment, nor are we liable for any injuries that may result from its use. It is your full responsibility to keep your equipment regularly serviced and maintained. Once the equipment is handed over to you, you are solely responsible for how it is used and handled.

By signing below, you acknowledge that you have read, understood, and agree to the terms of this disclaimer.
Declaration: I, hereby declare that all information provided above to obtain Medical equipment is true and accurate. I understand that any false information given to obtain Medical equipment by deceitful actions will result in appropriate consequences and may involve the police. I agree to sign this declaration to acknowledge my understanding and acceptance of all the terms and disclaimers.*

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Date of referral *

DayMonthYear
If you have answered yes to the last two questions and have supplied the proof required, i.e. a hospital letter stating your name, address, Diagnosis/ Chronic illness (any other info such as NHS number and medical summary can be blacked out), your items will be sent out within 72hrs. Occasionally we may need to signpost you.
Should be Empty:

Referral for Equipment

DISCLAIMER AND ACKNOWLEDGMENT: