Powered Mobility Manual - Cerebral Palsy Alliance

Appendix 12.5Final Prescription SummaryNameDOBClient NumberComplete each section to ensure all components are recorded.PWC BaseDetails:SeatingDetails:Supplier:Supplier:Date of final quote:Date of final quote:Control System (method of access)Details:Other DetailsFunding source/s: (list each)Date applied: Entered on Equipment registerDate approved:Other equipment for interfacing: (please list)Supplier:Date of final quote:Specialist service involved?ContactPhIndividuals required at equipment fitting/delivery:(please list)Therapist nameSignatureDate87