You can, should you wish, download a printeable version of this form by clicking here.
Client Contact number:
Job title or relationship to the client:
History of presenting condition and relevant past medical history:
Problems with existing seat/wheelchair/shower-chair:
If Client currently a wheelchair User:
Pressure Risk: Note any existing or previous pressure or moisture damage – grade/location
HoistStand-aidCarer assist to standingIndependently standing
Will the chair need to be moved with the client in it?YesNo
Door widths, steps, other issues for access –please describe and provide measurements
We are still able to deliver equipment to our clients, whilst ensuring that we stick to the current guidelines, by completing a Contact-Free delivery. The driver will bring the equipment to the door of the property and hand it over to the client or carer whilst maintaining a 2 metre distance, in line with Covid-19 recommendations. It is the client’s responsibility to ensure that there is suitable access to allow them to get the equipment into its desired location.We are able to complete a follow up phone/video call if any further instruction on the equipment is required.
Please confirm that you have read and understood our terms and conditions(see below):
The new General Data Protection Regulations are changing a number of ways that companies use and store customer data.
We would like to assure you that at Advanced Seating Solutions Ltd. we respect your privacy and will store your information in line with our Privacy Notice & Data Protection policy (to be found here). We will only use your data to send you information relevant to your field of interest. We will not share your data with third parties without your knowledge and you can unsubscribe at any time.
Guidance for taking required measurements:
It is important that the measurements you take are consistent, accurate and clear to us. Be sure the measurements you are providing are that of the client not the existing chair, as they are different. We prefer you to measure the client and then we will discuss with you what seat depth, height and width the client will require.
Use inches or centimetres as is your preference, but again make that clear and if using a fabric tape measure make sure that the measurements are ‘straight line’ rather than being shaped around the client as this will give you a different result.
Check that the client is wearing their usual footwear during measurement. For example, if they normally wear slippers then assessing and measuring them whilst wearing heeled boots would make a big difference to the result and any recommendations.
Measure the width of the bottom in in a seated position so that you take into account any spread. Find the widest part across the hips and measure with a metal tape measure (if using a fabric measure ensure it is held taut)
Ensure that the measurement is taken from the rear most point of the bottom to the crease behind the knee and that the client’s bottom is as far back in the chair as possible.
Measure from the floor to the crease behind the knee. This measurement is critical as it supports the pelvic angle. The thighs should be horizontal to the seat base and at no point should the knees be higher than the pelvis unless the client is in a fixed position. Please make this clear if that is the case.