Power Wheelchair Assessment Request Form

Thank you for allowing Active Mobility the opportunity to provide equipment for demonstration and assessment. Please fill in the form below to help us best meet the needs of your client. By providing as much information as possible, we will have the best chance of a successful outcome in the trialling stage.

Please select the relevant boxes or type details as required.

Is this assessment?*

What form of funding will you be seeking for this equipment?*

What style of wheelchair do you wish to evaluate?*

Rear Wheel Drive

Mid Wheel Drive

Which of the following power functions are you interested in?*

Is the wheelchair to be used?*

What type of control is required?*

Which of the following seating accessories would you like to see on the assessment wheelchair?

What style of backrest would you like on the assessment wheelchair?*

What style of cushion would you like on the assessment wheelchair?*

What style of armrests would you like on the assessment wheelchair?*

What style of legrests would you like on the assessment wheelchair?*

Client details (* indicates mandatory field - this form cannot be submitted without these dimensions.)

Notes - Please add any further details relevant to this assessment e.g. property access issues, infection control requirements, client behavioural concerns.

Upload Photos - you can upload up to 3 images of your client and/or existing equipment to help us prepare the assessment chairs. All media will be treated and stored in strict confidence.