Designing and Building Wheelchair Ramps

Office/Facility Name

File

Max. file size: 100 MB.

**Ordered by

Print Name

Phone#

Patient Name

DOB

Length of Need (1 to 99)

Please enter a number from 1 to 99.

Diagnosis/ICD10

Height

Weight

Discharge Date

Physician’s full name

Rollator Walker w/seat & brakes

Rollator Walker w/seat & brakes

6"
8"

Standard Walker

Standard Walker

Standard Walker

Standard Cane

Standard Cane

Quad Cane

Quad Cane

Quad Cane

Large Base
Small Base

Knee Walker ($39 a month)

Knee Walker ($39 a month)

Crutches

Crutches

Crutches

Youth
Adult
Tall

Wheelchair

Wheelchair

Size

or (Circle one ) 16X16 16X18 18X16 18X18 20X16 20X18 22X18 24X18 26X20 28X20 30X20

Wheelchair

Light Weight
Reclining
Transport
Power Mobility Device
Gel Cushion
Foam Cushion
Roho Cushion

Wheelchair Accessories

Foot Rest
Anti-Tippers
Brake Extensions
Wheelchair Back Cushion
O2 Holder for W/C
Adustable Height Arms

Elevating Foot Rest

Elevating Foot Rest

Elevating Foot Rest

L
R

Transfer Board

Transfer Board

Transfer Board

24"
30"

Half Lap Tray

Half Lap Tray

Half Lap Tray

R
L
Hemi-kit

Hospital Bed (Full Electric)

Hospital Bed (Full Electric)

Hospital Bed (Full Electric)

Half Rails
Full Rails
APP Pad and Pump
Group One Mattress (Memory foam)
Group Two Air Mattress
Standard w/APP Pump
Standard Innerspring

Arm Trough

Arm Trough

Arm Trough

R
L

Oxygen at

Oxygen at

(Please provide documentation)

LPM

HPD (Hours Per Day)

Saturation Rate (under 88)

Standard Commode

Standard Commode (up to 300 lbs.)

Bariatric Commode

Bariatric Commode (over 300lbs.)

Drop Arm Commode

Drop Arm Commode

Bariatric Drop arm Commode

Bariatric Drop arm Commode

Hoyer Lift

Hoyer Lift

Sit to Stand

Sit to Stand

SLING OPTIONS

U sling w/head support
Full Body Sling w/commode opening

Other

Other

others

Phone

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