Northamptonshire NHS Wheelchair Service

Please ensure that all sections are completed in full.

Failure to do this may result in unnecessary delays.

You must have a permanent physical impairment or medical condition that affects your ability to walk and will need a manual wheelchair for more than 6 months.

The wheelchair must be required for indoors or indoors AND outdoors.

Outdoors only wheelchairs will not be provided.

Personal Information

essential information*

NHS No. *

You can find your NHS number on a prescription form, prescribed medication bottle or appointment letter.

Error: NHS Number is required

Name *

Title

First Name

Please specify an answer

Last Name

Please specify an answer

Address *

Address

Please specify an answer

Address2

Please specify an answer

Town

Please specify an answer

County

Please specify an answer

Postcode

Please specify an answer

Birth Date *

E-mail

Please specify an answer

Birth Date

example@example.com

Phone Number *

Mobile Number

Please specify an answer

Please enter a valid phone number

If different from main number

Personal Information

essential information*

Gender *

Male

Female

Prefer not to say

Ethnic Origin *

Religion

Please specify an answer

Do you already have an NHS Wheelchair? *

Yes

Unsure

Height *

Metres

Invalid measurement

Feet

Invalid measurement

Inches

Invalid measurement

Weight *

Kilos

Please specify an answer

Stones

Please specify an answer

Lbs.

Please specify an answer

GP Information

essential information*

GP Name *

Please specify an answer

GP Address *

Please specify an answer

Max characters: 500

About You

Any additional information you would like us to know? *

Please specify an answer

Max characters: 5000

Privacy and Data Storage Consent

The information you provide in this form is used solely for processing your enquiry and will not be used for any other purpose. Blatchford do not store any backups of the information provided and any information you submit is sent directly to the NHS.

For more information, please see our Privacy Policy.

GDPR Consent *

I acknowledge that any personal data submitted by me will be processed in accordance with Blatchford's Privacy Policy

Please check through the information you have provided before pressing the Submit button below

Personal Information

essential information*

NHS No.

@NHSNumber

Name

@Title @FirstName @LastName

Address

@Address

@Address2

@Town, @County

@PostCode

Date of Birth

@BirthDate

Email

@Email

Phone

@Phone

Mobile

@Mobile

Gender

@Gender

Ethnic Origin

@Origin

Religion

@Religion

Do you already have an NHS Wheelchair?

@NHSWheelchair

Height

@HeightMetres Metres

@HeightFeet Feet @HeightInches Inches

Weight

@WeightStones Stone @WeightLbs Lbs.

@WeightKilos Kilos

GP Name

@GPName

GP Address

@GPAddress

About You

Medical History and current issues relevant to mobility

@History

How do you move around your home?

@Mobility

What type of wheelchair do you require?

@WheelType

How do you get in and out of your chair?

@Transfer

How often will you need to use the wheelchair?

@Frequency

Where will you use the wheelchair?

@Usage

Do you have any pressure areas or vulnerable skin prone to breakdown?

@PressureAreas

Location: @PressureAreasLocation

Do you have any issue with toileting?

@Continence

Comments: @ContinenceComments

What type of building do you live in?

@Property

Can you sit in a chair unsupported?

@Posture

Would you like a PWB?

@PWB

Any additional information you would like us to know

@AdditionalInfo

I confirm the above information as true

Name of the person completing this form *

Please specify an answer

Relationship to patient *

I am the patient

Carer

Referrers Telephone *

Please specify an answer

Referrers Address *

Please specify an answer

Max characters: 500

Your referral has now been submitted.

Northamptonshire Wheelchair Service will contact you if we require further information or once the referral has been processed within 5 working days