Sensible Care

Physiotherapy Equipment Recommendation

Full Name:

DOB:

Assessment Completed By:

Date of Assessment:

Assessors Email:

Referrers Email:

Date of Recommendation:

Showroom Address (if a trial was done):

Street address

Suburb

State

Postcode

Equipment Name:

Link to Equipment:

Other Information (price, suppliers, alternative options, etc.):

Product Code:

Product Comparison:

Alternative Supplier:

Rationale/Reasoning:

Service

Function

Item Description

Safety Considerations (ability to use independently/with supervision, cognitive level, pain fatigue level, etc.)

Attachment:

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