Basic Equipment Referral Form - Canadian Red Cross

Health Equipment Loan ProgramVancouver/Richmond/North Shore Short Term Loan Referral FormPlease contact your local Red Cross to confirm equipment availabilitywww.redcross.ca/helpClient: Last Name:________________________________________ First Name:_________________________________Address:________________________________________________ City: _______________________ Province: _______Postal Code: ______________ Phone Number: _____________________ Birthyear (YYYY): ______ Gender: M / FHeight (cm/in): _________ Weight (kg/lb): _________ Personal Health Number _________________________________Additional Information: ______________________________________________________________________________Alternate Contact: Name:_____________________________________ Phone Number:__________________________Adjustable Bath ChairBack or No BackBath BoardFlushBath Transfer BenchArm on Right Arm on LeftPadded or PlasticBathtub Safety RailClamp On or SuctionOther _________________________CommodeStationaryWheeledPediatricShowerOther: _________________________CrutchesCrutch Height: _____________ InchesAxillaPediatricForearmHand grip Height: ___________inchesGutter AttachmentGutter-Floor Height: ________inchesLeft Right BothFrame WalkerHandgrip-Floor Height: _______inchesTwo Wheels or No WheelsPediatricWideGlide BrakesGlide Caps/Ski (recommended forcarpet)Gutter AttachmentGutter-Floor Height: ________inchesLeft Right BothWalker TraySide/Hemi WalkerHandgrip-Floor Height: _______inchesRaised Toilet Seat2” 4” 5”/6”Left Cut Out Right Cut OutClamp OnNo Clamp5” With Attached Arm RestsElongated toilet seat elevatorToilet Safety FrameCaneCane Height: _______________inchesSinglePairQuad CaneRight SideSmall BaseLeft SideLarge BaseWheelchairStandardPediatricTransport RecliningSeat Width:12” 14” 16” 18” 20”22” 24”Seat-to-Floor Height:Standard (19”) Hemi (17.5”)(All chairs come with footrests)Elevating Leg Rests:Right Left BothOther: _________________________Four Wheeled WalkerSeat-Floor Height: ___________inchesHandgrip-Floor Height: _______inchesStandardWideBasketTrayOther: _________________________OtherBed AssistIV PoleBed CradleOverbed TableReferring Health Care Professional: Full Name: ___________________________________________________________Signature: _____________________________________ Phone Number: ______________________________________Professional Designation (circle one): RN / OT / PT / DR / Other (specify): _______________________________________Place of Work: _________________________________________ Anticipated Length of Loan: 1___ 2___ 3___ month(s)Additional Information:______________________________________________Referral Date: ______- ______ - ______Month Day Year

HELP LOCATIONSBC Lower Mainland RegionAs of March 1, 2009, all equipment loans require a referralfrom a regulated health care professional.These volunteer-operated sites are normally open at the posted hours except on statutory holidays and long weekends.AbbotsfordMon – Sat 11:00 am – 1:00 pm#5 – 2316 McCallum RoadAbbotsford, BC V2S 3P4T 604-556-3526F 604-556-3546Port CoquitlamMon – Fri 10:00 am – 1:00 pmSat 10:00 am – 4:00 pm#104 – 1776 Broadway StreetPort Coquitlam, BC V3C 2M8T 604-944-9042F 604-944-9073BurnabyMon – Sat 9:30 am – 12:30 pmEdmonds Neighbourhood CommunityResource Centre#105 – 7355 Canada WayBurnaby, BC V3N 4Z6T 604-522-7092F 604-522-1853RichmondMon – Fri 8:30 am – 12:00 pmSat 9:00 am – 2:00 pm#108 – 2931 Olafsen AvenueRichmond, BC V6X 2R4T 604-278-4011F 604-278-0741ChilliwackMon – Fri 9:00 am – 12:00 pm9290 Mary StreetChilliwack, BC V2P 4H4T 604-792-2343F 604-792-2783SquamishMon/Wed/Fri 9:00 am – 12:00 pm38150 Behrner Drive, P.O. Box 992Squamish, BC V8B 0A7T 604-892-5318F 604-892-5308LangleyMon – Fri 9:00 am – 12:00 pm#101 - 9770 196A Street(off Telegraph Trail)Langley, BC V1M 2X5T 604-881-1113F 604-881-1125SurreyMon – Fri 9:00 am – 12:00 pmWed 6:00 pm – 8:00 pmSat 9:00 am – 3:00 pm#109-14727 108 th Ave.Surrey, BC V3R 1V9T 604-930-9049F 604-930-9036Maple RidgeMon/Wed/Fri12:30 pm – 4:00 pm#5 – 11435 201A StreetMaple Ridge, BC V2X 0Y3T 604-465-5050F 604-465-5054VancouverMon – Sat 9:30 am – 4:00 pm209 West 6 th AvenueVancouver, BC V5Y 1K7T 604-301-2566F 604-301-1162North VancouverMon – Fri 9:00 am – 4:00 pmDelbrook Recreation Centre(North Building)600 West Queens RoadNorth Vancouver, BC V7N 2L3T 604-988-7115F 604-988-7105White RockMon/Tue/Thu/Fri/Sat9:30 am – 12:30 pmWed 1:30 pm – 4:30 pm#16 – 1480 Foster StreetWhite Rock, BC V4B 3X7T 604-536-7911F 604-536-7956Updated: March 1, 2012BC Lower Mainland Regional Office | 3400 Lake City Way, Burnaby, BC V5A 4Y2T 604-709-6600 (Switchboard) / 1-800-565-8000 (Toll-free)F 604-709-6675 (Main) / 604-709-6688 (Health Equipment Loan Program)www.redcross.ca/lowermainland