Client Information

Date of Birth*

Therapist Details

A copy of this application will be sent to this address

Funding Source

What is the expected funding source for this item?

Client Diagnosis

Bed and/or Mattress Requirements

What are the key requirements in a bed? (Select all that apply)

Do you require Lightning Mobility to supply a mattress?

What size bed does the client want?

Please note: some funding bodies may only fund bed sizes above king single in exceptional circumstances.

Custom Sizes

Specify custom sizes if required or known