GTK Rehab - Rehabilitation Technology Supplier.

To book an appointment with our staff please Complete and return the following form by fax to GTK Rehab.  

Fax: (02) 9620 9081

1. Client Information.

Today's Date:
Name: 
Male or female:
Date of birth:
Age:
Height (in millimetres):            
Weight (in kilograms): 
Address:
Phome (home):
Phone (work):
Funding source (Private, PADP, Other);
Location for appointment:  

2. Medical Details (Diagnosis/Disability).

Please specify yes or no for the following:
* Seizures:
* Cardiovascular difficulty;
* Breathing difficulty:
* Swallowing difficulty:
* Asymmetrical posture:
* Past or planned surgery (if yes please list):
* Dislocated hips (if yes please indicate right, left or both):
* Pain (if yes please mention location and severity):
* Pressure areas (if yes please mention location and severity):
* Muscle Tone (Describe):

3. Current Seating / Mobility: 

Please specify yes or no for the following and provide details were relevant:

Powered Wheelchair:
* Type:
* Method of Control:
* Age/Condition:
* Approximate Size: 
* Seat Width:
* Seat Depth:

Manual Wheelchair:
* Type:
* self propelling:
* Age/Condition:
* Approximate Size: 
* Seat Width:
* Seat Depth:

Special Seating:
* Wheelchair cushion type:
* Wheelchair back type:

Extra Equipment:
* Please list:

4. Please list any concerns you may have regarding their current wheelchair and/or Seating or posture.

5. Please let us know the equipment you would like GTK to bring to the appointment and width of frame:

6. Your details:

Your Name:
Your Role:
Your Contact Details:
Phone:
Fax:

Thank You. We Will Contact You By Phone Or Fax To Arrange A Suitable Time.  

End of form.