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

Is client already using powered mobility?

Power Wheelchair Requirements

Will the wheelchair be independently controlled, attendant-propelled or both?

Will the wheelchair be used in a wheelchair taxi?

Please note: not all power wheelchairs are legally allowed to travel in wheelchair taxis. If this is a key requirement for the wheelchair user, please let your Lightning Mobility Representative know.

(i.e. pressure care concerns, stump support needed, space for an oxygen bottle, client interested in particular brand). If unsure, ask your OT or Lightning Mobility Representative.

Client Measurements

Please provide as much anthropometric data as possible, as it helps to set up the chair for demonstration prior to the appointment.

Please enter measurements in either cm's or inches

A Top of Shoulders

(Cm)

(Inches)

B Chest Depth

(Cm)

(Inches)

C Chest Width

(Cm)

(Inches)

D Seat Depth

(Cm)

(Inches)

E Top of Head

(Cm)

(Inches)

F Elbow to Head

(Cm)

(Inches)

G Seat Surface to Elbow

(Cm)

(Inches)

H Hip width

(Cm)

(Inches)

I Knee to Floor

(Cm)

(Inches)

Upload any pictures, documentation to assist with your enquiry