Regional Rehabilitation Outpatient Services
Adult Wheelchair & Seating Clinic
Hamilton Health Sciences Corporation, General Site
Regional Rehabilitation Centre, 237 Barton St. East, Bldg. 2, Hamilton, ON L8L 2X2
Telephone: (905) 521-2100, Ext. 40806 Fax: (905) 521-2359
THIS PAGE TO BE COMPLETED BY PHYSICIAN
CLIENT NAME____________________________________________PHONE_________________________
ADDRESS________________________________________________________________________________
________________________________________________________POSTAL CODE____________________
DATE OF BIRTH ______/______/______HEALTH INSURANCE #__________________________________
D
M
Y
RELEVANT DIAGNOSIS _________________________________ LENGTH OF TIME ________________
PERTINENT MEDICAL INFORMATION (include conditions, allergies & medications which may affect
seating prescription)_________________________________________________________________________
__________________________________________________________________________________________
Current Medical Status_______________________________________________________________________
__________________________________________________________________________________________
Physician Name (please print): ________________________________________________________________
Address: _________________________________________________________Postal Code: ______________
Phone: (
)____________________________________Fax: (
)_______________________________
Physician Signature ________________________________________________ Date ____________________
Page 1 of 3
December 7, 2009
Regional Rehabilitation Outpatient Services
Adult Wheelchair & Seating Clinic
Name_________________________________________________Phone ________________________
Address______________________________________________________________________________
_______________________________________________________Postal Code____________________
Date of Birth ______/______/________
D
M
Y
Health Card Number _______________________________
Version Code__________ Expiry Date_________________
Family Physician ___________________________________________Phone______________________
Do you have a Community Therapist?
 Yes
 No
Therapist’s Name __________________________________
Agency ______________________________________ Phone _______________________
 Yes
Has there been any equipment trials recently completed ?
Do you currently have a wheelchair?
 Manual Wheelchair
 Power Wheelchair
 Yes
Model
Model
Do you have special seating in your wheelchair?
 Back Support
 Cushion
 Manual tilt/recline
 Other





What are your current wheelchair/seating
concerns?
 Pain/Comfort
 Posture/Sitting support
 Condition of current wheelchair
 Other
Comments
Page 2 of 3
December 7, 2009
 No
 No
Yes
 No
Side Supports
Tray
Power tilt/recline
Elevating legs
 Pressure area/Skin breakdown
 Mobility
What are your goals for clinic involvement?
 New manual wheelchair
 Improved posture
 New back support
 Improved mobility
 Other (specify)
Comments
 New power wheelchair
 Improved pressure reduction (manual/power tilt)
 New cushion
Power of Attorney for Personal Care (if applicable)
or Substitute Decision Maker
Name
Power of Attorney for Finances (if applicable)
Relationship
Name
Phone
Relationship
Phone
Vendor for wheelchairs and seating
(see attached list)
Vendor for custom seating
Consent for Personal Information: I give consent to the Adult Wheelchair and Seating Clinic to collect
information about me related to my need for wheelchair and seating/positioning. I understand that this
information may be disclosed, as needed, to other members of the care team including, but not limited to, family
doctor/referral source, vendor, Ministry of Health Assistive Devices Program (ADP). I understand that the
collection and disclosure of information is within the guidelines as established by the Privacy Policy.
_______________________________________________________________________________________
For use of Email Communication only:
This section disregarded-email communication NOT appropriate
OR
I agree to allow personal and health information to be sent via email, even though I am aware it may not be
secure.
Yes
No
Pertinent information about me may be sent to the following : equipment supplier
Family member
Other:
Signature
Date
If signature is other than client, please identify
relationship
This form must be completed in full before an appointment can be made
Return to :
Eleanor Walters, Intake Coordinator
Hamilton Health Sciences
Regional Rehabilitation Centre
237 Barton St. East, Bldg. 2, Hamilton, ON L8L 2X2
Phone: (905) 521-2100 Ext. 40806
Page 3 of 3
December 7, 2009
FAX:
(905) 521-2359