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JUST THE INFORMATION YOU NEED!

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City: Pos t Code:
Street: Suburb:

Town/City: State:
Profes s ion: OT PT SLT VNT Other:

The age group that I work with most is: Paediatric (General 0-21) All Ages Adults
Older Peoples Health Early Intervention (0-3) Primary (3-8) Secondary (8-16) Late Teens (16-21)

Product information that I am interested in includes:

W/Chair Seating Wheelchairs Pushchairs & Strollers
Vehicle Seating School & Task Seating Supportive Lounge Seating

Standing Aids Walking Aids Bathroom/Toileting Aids

Sleep Systems/Beds Limb Supports Other:
The three mos t common diagnoses that I encounter in our service are:

A) Most common B) Next most encountered C) Lesser Encountered
Cerebral Palsy Muscular Dystrophy Spina Bifida

Developmental Delay Spinal cord injuries Orthopaedics

Autism Neurological Conditoins (ie M.S, Parkinsons, Stroke)
The primary type of service I work in at address above is :

Community Service (Adult) Hospital Team Residential Care/Rest Home
s
rder Form
Child Development Mobility Assessment Private Practice
School Rehab Centre: ABI/Spinal Vocational Rehab

If other than the s election offered, pleas e s tate:
Please s end me your product information & keep me up-to-date including:

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Medifab thanks you for your registration of interest regarding our KIDDIEQUIP products
Fax this to us on 028 7134 7575
or scan & email to sales@creative-activity.co.uk
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Office: MF TH Region: R1 R2 R3