Please use this form to request a wheelchair or a special seating item for clients who have a permanent disability.

To avoid delays, please make sure every section of the form is filled in. Forms that are not complete cannot be accepted and will be sent back to the referrer.

We accept referrals from trained health or social care professionals, such as:

  • nurses
  • GPs
  • therapists
  • social workers

For urgent referrals, such as for patients with life‑shortening conditions, we will respond within 3 working days.

There is a short waiting list for powered wheelchair assessments, but no waiting list for other assessments.

Your client's details

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Address Required
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GP surgery address Required
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Do they have sitting balance? Required
Where will the chair be used? Required
How is the chair propelled? Required

Your details (the referrer)

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Address Required
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Privacy policy Required