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New Patient:
Wheelchair Self Referral Form (manual wheelchairs only) 

Please complete this form if you are new patient only - Rotherham clinic

Existing patients please contact 01709 916889 (option 1, then 3) or email  [email protected]

 

Please ensure that all sections are completed in full.  Failure to do this may result in unnecessary delays. 

You must have a permanent physical impairment or medical condition that affects your ability to walk and will need a wheelchair for more than 6 months.

* Required fields

 

Wheelchair Patient Self Referral:

NHS info
Needs to be 10 digits

You can find your NHS number on a
prescription form, prescribed medication bottle or appointment letter.

GP Information
Who is completing this form?
Patient Details...
Please do not enter dashes
Patient Height


Patient Weight




Current Health & Mobility...















Your New Wheelchair...










Additional Factors...











Personal Wheelchair Budget (PWB)



Anything Else?
Privacy and Data Storage Consent

The information you provide in this form is used solely for processing your enquiry and will not be used for any other purpose. Blatchford do not store any backups of the information provided and any information you submit is sent directly to the NHS.

For more information, please see our Privacy Policy.