Assessment and prescription form for specialist pressure relieving equipment

The following form is for use by healthcare professionals only.


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You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Please note: For same day installation, orders must be recieved before 2pm

If a hospital bed is required for the patient please order this through Mediquip

Is the patient going home for end of life/palliative care?
Can the patient move themselves from side to side in bed?
Can the patient move themselves in their chair or wheelchair?
Is the patient bed bound?
Has a seating and/or wheelchair assessment been carried out?
Has a moving and handling assessment been made?
Type of bed at home:
Type of chair at home:
Has cot side height safety assessment been done?
Is the patient incontinent of:
Assumed cause of pressure ulcer:
I confirm that I am a qualified healthcare professional: