Equipment Request Form
Voice Related Devices and Respiratory
Consumables
New Request
Amendment to Existing Request
1. CLIENT INFORMATION
Client Name
Last Name
ENABLE #
First Name
Title
Mr
Mrs
Ms
Miss
Other
Date of birth:
Address
Suburb
Postcode
Phone
Mobile
Contact person (if not client)
Relationship
Partner
Parent
Phone
Mobile
Email
Relative
Carer
Friend
Email
Diagnosis
Date of surgery:
Date of Discharge:
N/A
2. EQUIPMENT RECOMMENDATION
New
Product
Replace
ment
Product
Product name and Code
Supplier
Supply Allocation*
Electrolarynx
one per consumer
Indwelling Voice Prosthesis
2/year
OR
Non Indwelling Voice Prosthesis:
6/year
Trache-oesophageal Dilator:
one per consumer
Gel Cap Insertion Kit:
one pack per
consumer
Gel Caps:
one pack per
consumer
Cleaning brushes/ flushing device:
one pack per
consumer
Tracheostoma/Hands Free Speech
Valve Starter Kit:
Cost
one per consumer
Justification required – see below
ERF_ EnableNSW _ Voice Related Devices and Respiratory Consumables July 2014
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Equipment Request Form
Name:
Date of Birth:
Heat Moisture Exchangers
(including foam stoma covers):
365/year
Tracheostoma Button:
1/year
OR
Standard Adhesive Seals:
365/year
OR
Non standard Adhesive Seals:
180/year
Justification required – see below
Laryngectomy Tube:
1/year
Neck Straps:
12/year
TOTAL COST (Office Use)
$
*This is the standard annual allocation and actual quantity may vary depending on packaging
4. EQUIPMENT JUSTIFICATION
a) Has the surgical site stabilized?
Yes
No
b) Will the equipment be required on a permanent basis (≥ 12 months)?
Yes
No
c) Is the consumer able to use the recommended equipment safely and appropriately,
Yes
No
Yes
No
Yes
No
including care, maintenance and emergency planning in the event of equipment
failure?
d) Is the consumer/carer aware of the annual allocation through EnableNSW and has
information regarding purchase of additional supplies if required?
e) Has a trial on all the requested equipment been completed?
f) If requesting increased annual allocation of indwelling voice prosthesis, and/or provision of non-standard
adhesive seals, and/ or a tracheostoma/hands free speech valve, please provide clinical justification to
support the request. Please refer to Voice Related Devices and Respiratory Consumables Clinical Criteria.
N/A
ERF_ EnableNSW_ Voice and Respiratory Devices Aug 2013
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Equipment Request Form
Name:
Date of Birth:
g) Are any changes anticipated that may impact on this equipment request?
(e.g. change to size/type of device)
No change anticipated.
Yes. If yes, please recommend appropriate supply schedule.
h)
i)
i)
Is the consumer aware of and in agreement with this equipment request?
Yes Date agreement received:
No N.B. Application will only be processed with consumer/carer agreement.
A copy of the equipment request has been provided to the consumer.
Yes
Date
No If no, why?
Name and contact details of local speech pathologist (if different to prescriber):
OR
See prescriber details below
5. DELIVERY INFORMATION
a)
Who should be notified when the equipment is ready to be delivered?
Prescriber
Consumer/contact person
Other Provide contact name, relationship, phone, email
b)
Delivery address for equipment
Consumer’s home address
Other, provide details
c) Delivery Instructions
Yes
No
If yes, details:
6. PRESCRIBER DECLARATION
Please provide the name, address and contact details of the prescriber
Name:
Address:
Service:
Days/hours available:
Qualification/role:
Phone:
Email:
DECLARATION
I declare that I have assessed the consumer in consultation with an appropriate multidisciplinary team and
have the required qualification and level of experience to prescribe this equipment according to the Professional
Criteria for Prescribers.
Signature:
Supervisor name, name of service, address, phone, email:
(if required)
Date:
Signature of supervisor (if practical):
Qualification:
Days/Hours available:
Date:
NB: Incomplete forms will delay processing of the application. Please ensure all contact details are provided.
ERF_ EnableNSW_ Voice and Respiratory Devices Aug 2013
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