Front Wheel Drive
Rear Wheel Drive
Mid Wheel Drive
Early Intervention Paediatric
Pressure Care Overlay
SmartDrive MX2+ Pushtracker
Power Lift Chairs
High Pressure Day Chairs
Date of Birth*
A copy of this application will be sent to this address
What is the expected funding source for this item?
How is the client’s NDIS plan managed?
What are the key requirements in a bed? (Select all that apply)
Do you require Lightning Mobility to supply a mattress?
What type of mattress?
What size bed does the client want?
Please note: some funding bodies may only fund bed sizes above king single in exceptional circumstances.
Specify custom sizes if required or known
A Back rest size
C Small Kneebreak
D Large Kneebreak
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