North East Drive Mobility - Powered Wheelchair and Mobility Scooters Self Referral Form :: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Please complete as much information as possible; if you would like to discuss any aspect of your referral, please contact North East Drive Mobility Tel: 0191 2875090

Please note powered chair and mobility scooter assessments can only be carried out at our Newcastle Centre

Personal details

Full name Required

DOB Required

Address Required

Home phone Required

Mobile Required

Email Required

GP details

GP Name Required

GP Practice Required

Address Required

Medical history and current functioning

Diagnosis and how the condition affects you Required

Relevant past medical history (please include any relevant cognitive assessment results) Required

Height Required

Weight Required

Physical ability Required

Indoor mobility Required

Outdoor mobility Required

Transfers Required

Do you currently have: Required

A powered chair

A mobility scooter

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North East Drive Mobility - Powered Wheelchair and Mobility Scooters - Health Professional Referral Form

North East Drive Mobility - Powered Wheelchair and Mobility Scooters Self Referral Form

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GP details

Medical history and current functioning

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North East Drive Mobility - Powered Wheelchair and Mobility Scooters Self Referral Form

Personal details

GP details

Medical history and current functioning

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