AHP Equipment Request Form

AHP Equipment Request Form
Client Details

Clients WILL be registered with MND Queensland and we must have client details and signed consent to process loans, however there is no obligation to be a Member of MND Queensland.
Client Name*

First NameLast Name
Client Phone Number*

Area CodePhone Number
Client Email
We Require either a client email address of Next of Kin Email Address
Client Diagnosis*
E.g. MND or ALS, PBP, PMA, PLS
Client DOB*
Client Communication *
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Access to Property Concerns (e.g Steep Driveway)
Next of Kin Name*

First NameLast Name
Relation to Client
Next of Kin Phone*

Area CodePhone Number
Next of Kin Email
We Require either a client email address of Next of Kin Email Address
Funding Details
Funding Source*

NDIS FundedNDIS Eligible/Application PendingMy Aged Care FundedSelf FundedEligible for MND QLD free equipment program (people with MND with no government funding or fully utilising their My Aged Care pacakges for other vital services are eligible)
NDIS Support Coordinator's Name

First NameLast Name
NDIS Support Coordinator's Company
NDIS Support Coordinator's Email
example@example.com
NDIS Support Coordinator's Phone Number

Area CodePhone Number
NDIS Number*
This is found on any letter received from NDIS
Plan Start Date *

DayMonthYear
Date
Plan End Date *

DayMonthYear
Date
Is the Assistive technology Budget:*

Agency ManagedPlan ManagedSelf Managed
Invoice Email*
example@example.com
Referring Allied Health Professional

Please fill your details below.
Name*

First NameLast Name
Occupation *
Company Name*
Referring AHP Email*
example@example.com
Office Phone Number*

Area CodePhone Number
Mobile Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Work Hours
Equipment Required

Please Select Equipment Required *

	Select All Required	Please Indicate Size W x L (Inches)
Mobile Shower Commode
Mobile Shower Commode Tilt In Space
Shower Chair
Toilet Seat Raiser
Electric Bed and Foam Mattress (Single size)
Electric Bed and Foam Mattress (King single size)
Alternating Air Mattress
Repose Overlay
Hoist with Sling (Sling size and type Yoke/Pivot)
EyeGaze
Recliner (Single Motor)
Recliner (Dual Motor)
Regency Chair
4 Wheel Walker
Pressure Cushion
Manual Wheelchair
Power Wheelchair
Cough Assist Machine
Portable Suction Unit
NeuroNode + IPad
Recliner (Quad Motor)
Other (Please Detail Below)
EyeGaze Stand (by itself)
Manual Wheelchair (Tilt in Space)
Trilogy
OBI Feeder

Please let us know if there are special requirements (eg special attachments) *
Please indicate stand attachment for EyeGaze if selected.
By completing this request I agree:
- To provide training and support in the use of this equipment to the client and any other persons who need to be familiarised with its use and operation.
- I acknowledge that this equipment is from an equipment library, may not be new, and is provided to best meet the needs of the client.
- The equipment is not to be modified in any way without written agreement from MND Queensland, as stated in the MND Queensland Equipment Service Loan Agreement.
- Please confirm the client has consented to you sharing their information with MND Queensland and is aware that this will result in an electronic client record being created in their name on our client database for the purpose of retaining information necessary for the provision of services relevant to their care needs.
Please Sign to Complete Referral*

Clear
Please note: This request will be given a registration number for future reference and a copy returned to you within 7 days indicating the availability of items requested. Your client will also receive acknowledgement in writing of this request. Should you require a faster responce, please contact our office directly on (07)3372 9004.
Should be Empty:

AHP Equipment Request Form

Client Details

Funding Details

Referring Allied Health Professional

Equipment Required