Page Rehabilitation & Health Care Center

Wheelchair work order and Service Request forms.

 

Wheelchair Issue Form This for is to be used for the issuance or assignment of a wheelchair to resident, staff or department for use from standard inventory.
Wheelchair Cancelation or Removal This for is to be used for terminating the use or assignment of a wheelchair by a resident, staff or department.
Room Change This form is to be used for changing room assignments or updating wheelchair location records, in an effort to keep information current.
New Wheelchair PO This form is to request a wheelchair rental or purchase to accommodate a specific need.
Wheelchair Repair Request This form is to request repair of a wheelchair currently assigned to a resident.
Wheelchair Equipment Change This form is to request removal or addition of equipment mounted to a wheelchair currently assigned to a department, staff member or department.