Wheelchair Ramp Request Form
This form must be completed by the referring healthcare professional.
General Information
Client Full Name
*
First Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
*
example@example.com
Client Address (where ramp is to be built)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Client Information
Client's Age at Referral
*
DOB (MM-DD-YYYY)
Client Gender
*
Client Ethnicity
Is this a hospice patient?
*
Yes
No
Is this a dialysis patient?
*
Yes
No
Is this a handicapped person living alone?
*
Yes
No
Did this person serve in the military?
*
Yes
No
Client Financial Information
Is there a financial need, based on the referring agency's guidelines?
*
Yes
No
Does the Client Own or Rent their home?
*
Own
Rent
If Rent - Please provide Name of Owner
Full Name
If Rent - Please provide Contact Info of Owner
Phone Number
Email
Caretaker/Family/Other Contact Information
Caretaker Name and Relationship
*
Caretaker Contact Phone
*
Ramp Information
Where is the ramp needed? (Be specific: front of house, side door,etc...)
*
Provide a brief description of the obstacle(s) (e.g. a door threshold, asingle step, a mobile home with three steps, etc...)
*
Provide details of the client's mobility that are relevant to a ramp (e.g. walking, assisted walking, manual wheelchair, powered wheelchair, etc.). Also include a prognosis if this is expected to change.
*
Is there an existing dangerous ramp at the client's home?
*
Yes
No
Can the client/family provide any volunteers to help build the ramp?
*
Yes
No
Referring Healthcare Professional Information
Referring Social Worker/Doctor/Therapist Full Name
*
Name of Referring Agency
*
Referring Social Worker/Doctor/Therapist Phone
*
Referring Social Worker/Doctor/Therapist Email
*
Please upload the completed waiver from the Ramps page of the AMBUCS website. This waiver must be completed by the client. This can also be uploaded directly to the website.
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If waiver not uploaded to this form, please confirm it has been uploaded on the website directly.
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