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Service Users, Families, Friends and Carers

Health, Care and Education Professionals

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Pressure relieving equipment

Assessment and prescription form for specialist pressure relieving equipment

The following form is for use by healthcare professionals only.

To find out how we use this information, our security and your rights visit our privacy page.

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

Date of discharge *Required

Date / Date of birth

Is the patient going home for end of life/palliative care? *Required

Is the patient going home for end of life/palliative care?

Yes

Patient details

First name: *Required

Last name: *Required

Date of birth *Required

Date / Date of birth

NHS number:

Address: *Required

Postcode: *Required

Telephone number: *Required

GP name and address: *Required

Who will be available to accept delivery at the patients home/contact number/contact name: *Required

Medical history *Required

Medication:

Nutrition

MUST score: *Required

Weight (Kg) *Required

Height (metres): *Required

Waterlow: *Required

Mobility

Can the patient move themselves from side to side in bed? *Required

Can the patient move themselves from side to side in bed?

Yes

Can the patient move themselves in their chair or wheelchair? *Required

Can the patient move themselves in their chair or wheelchair?

Yes

Is the patient bed bound? *Required

Is the patient bed bound?

Yes

Who will help the patient change position? *Required

How much time does the patient spend in bed? *Required

How much time does the patient spend in chair? *Required

How much time does the patient spend in wheelchair? *Required

Has a seating and/or wheelchair assessment been carried out? *Required

Has a seating and/or wheelchair assessment been carried out?

Yes

If yes, on what date?

Date / Date of birth

Has a moving and handling assessment been made? *Required

Has a moving and handling assessment been made?

Yes

Type of bed at home: *Required

Type of bed at home:

Hospital bed

Profiling bed

Patients double bed

Patients divan

Bariatric bed

Other size bed

Type of chair at home: *Required

Type of chair at home:

Arm chair

Settee

Recliner

Riser recliner

Bariatric chair

Other chair

Bed rails

Has cot side height safety assessment been done? *Required

Has cot side height safety assessment been done?

Yes

Continence

Is the patient incontinent of: *Required

Is the patient incontinent of:

Urine

Faeces

Both

None

Skin changes

Category of pressure ulcer using NUPAP: *Required

Site of pressure ulcer: *Required

Depth of pressure ulcer: *Required

Width and length of pressure ulcer: *Required

Assumed cause of pressure ulcer: *Required

Assumed cause of pressure ulcer:

Friction/shear

Moisture

Pressure

Mixed aetiology

Present treatment *Required

Current pressure relieving equipment *Required

Suggested equipment required: *Required

Referer details

First name: *Required

Last name: *Required

Job title *Required

Manager: *Required

Telephone number: *Required

Based at:

I confirm that I am a qualified healthcare professional: *Required

I confirm that I am a qualified healthcare professional:

Yes

Referer email address: *Required

I agree to the privacy policy.

How to find us

Facilities and other info

Opening Times

Get in touch

By phone (general enquiries): 0300 123 3444

Via our customer experience team: MEDCH.customercare@nhs.net

Join our community forum: https://www.medwaycommunityhealthcare.nhs.uk/about-us/get-involved/community-forum

View our privacy notice: https://www.medwaycommunityhealthcare.nhs.uk/contact-us/privacy-notice

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