Pediatric Home Medical Equipment Lending Agreement Checkout

STLHELP Pediatric Equipment Checkout Form

St. Louis HELP: Taking back healthcare for families!
(For Children Ages 1–18)

This form is used to request and receive free pediatric home medical equipment from the St. Louis Health Equipment Lending Program (STLHELP) on behalf of a child ages 1–18.

A parent, legal guardian, caregiver, or pediatric healthcare professional must complete this form for all pediatric equipment.
Who is completing this form?*

Parent or legal guardianFoster parent or kinship caregiverOther caregiverPediatric Healthcare Professional
Child Information
Name*

First NameLast Name
Zip code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
County Where Child Resides*
Check all that apply*

Child has a disability or special healthcare needChild receives Medicaid/CHIP/other public benefitNeither apply
Child's age*
Parent/Legal Guardian
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Healthcare Professional
Healthcare Professional's name*

First NameLast Name
Name of Organization *
Employer of Healthcare Professional
Role*

Physical TherapistOccupational TherapistSocial Worker/Case ManagerOther
IMPORTANT: Enter 1 for each item you have requested. If you are receiving more than one of the same item, indicate that by providing the correct number.

	QTY
Activity Chair (pediatric)
Bath Chair
Bath Seat, Portable
Car Seat (Adaptive/Rehab)
Commode Chair
Crutches (pediatric pair)
Crutches, Forearm (pair)
Gait Trainer
Mat (therapy/exercise)
Patient Lift, Electric & Portable
Patient Lift, Electric (Power)
Patient Lift, Manual
Posterior/Reverse Walker
Potty Seat, Portable & Padded
Seating System (Soft)
Shower Chair
Shower Chair with Base
Shower Chair/Bedside Commode Combo
Sling, Full-Body
Stander
Stander, Sit-to-Stand
Standing (lift/assist device)
Standing Frame (pediatric)
Stroller, Folding (special-needs)
Stroller, Rigid (special-needs)
Toilet/Commode Supportive
Tricycle (adaptive pediatric)
Walker, Standard (pediatric)
Wheelchair, Manual
Wheelchair, Rigid (pediatric)
Wheelchair, Tilt in Space (pediatric)
Wheelchair, Transport (pediatric)
Wheelchair, Transport, Tilt in Space

Total Calculation*

	QTY	Weight	Price
Activity Chair (pediatric)
Bath Chair
Bath Seat, Portable
Car Seat (Adaptive/Rehab)
Commode Chair
Crutches (pediatric pair)
Crutches, Forearm (pair)
Gait Trainer
Mat (therapy/exercise)
Patient Lift, Electric & Portable
Patient Lift, Electric (Power)
Patient Lift, Manual
Posterior/Reverse Walker
Potty Seat, Portable & Padded
Seating System (Soft)
Shower Chair
Shower Chair with Base
Shower Chair/Bedside Commode Combo
Sling, Full-Body
Stander
Stander, Sit-to-Stand
Standing (lift/assist device)
Standing Frame (pediatric)
Stroller, Folding (special-needs)
Stroller, Rigid (special-needs)
Toilet/Commode Supportive
Tricycle (adaptive pediatric)
Walker, Standard (pediatric)
Wheelchair, Manual
Wheelchair, Rigid (pediatric)
Wheelchair, Tilt in Space (pediatric)
Wheelchair, Transport (pediatric)
Wheelchair, Transport, Tilt in Space
Total

If you chose "Other" as the type of equipment, please list what you received below.
Other Equipment Received

STLHELP Pediatric Equipment Checkout Form