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Wheelchair self-referral form

Online self-referral form for wheelchairs from South Tees Hospitals.

Personal details

Name(Required)
Address(Required)
Please note we are unable to direct issue equipment to patients under the age of 18. An assessment will be offered for anyone in this age group.
We can only provide equipment for permanent use. We cannot provide equipment for six months or less.
For example names of occupational therapist, physiotherapist, speech and language therapist…
For example name of social worker, support worker…
If you are unable to measure yourself, please try through your GP or state N/A. Please be aware that if you are unable to provide a height or weight or you are unable to provide the measurements in Section 3 then you will require an assessment for the provision of a wheelchair.
If you are unable to weigh yourself, please try through your GP or state N/A. Please be aware that if you are unable to provide a height or weight or you are unable to provide the measurements in Section 3 then you will require an assessment for the provision of a wheelchair.

Mobility details

How do you transfer?(Required)
How would you describe your ability to sit?(Required)
Also referred to as bed sores
Location, when, if the skin has/had broken down
Are you using any mobility equipment indoors?(Required)
How do you mobilise outdoors?(Required)
Do you receive any support with either your care or with your mobility?(Required)
Please provide details of who is providing the support
Do you use a wheel chair?(Required)
If you already have a wheelchair provided by wheelchair service then you will need to request a reassessment. You can also do this yourself by contacting us on 01429 522471.

Wheelchair details

Please be aware that you are unable to self-refer for powered chairs and this requires an assessment. If you are interested in the Personal Wheelchair Budget (PWB) this also requires an assessment.
The seat size is the width of the wheelchair seat. Measure across your lap, outside hip to outside hip without bending the tape measure. Be sure to add 1” / 2.5cm to promote comfort when sat in the wheelchair. If you are unable to provide the above measurement but you have provided a height and weight, then please put N/A.
What type of wheelchair do you need?(Required)
Privacy policy(Required)