Medical Adaptations Self Referral Form * an asterisk next to a field means it is a required fieldName of person requiring adaptation *Address of adaptation *Email address *Preferred contact numberName of person making the referral if different from aboveReason for adaptation *AgeDisabilityLong Term IllnessRelationship to the person requiring the adaptationFamily member Friend Doctor or other medical professional LHA employee Please tick to indicate what type of minor adaptation you require *External grab rail (Short plastic coated grab rail - styles may vary) External handrail (Tubular steel rail to assist with negotiating two or more steps at front door.)Internal stair banister (Properties will usually have at least one stair banister. A second banister can assist those with mobility issues when climbing stairs.)Internal grab rail (Plastic coated steel rail for internal use. )Lever taps (Provided in either the kitchen or the bathroom)Other (Tell us about your adaptation requirement below)OtherIf you'd prefer to speak to us direct about your medical adaptation self referral, you can contact Asset Management on 01224 423000 and a member of staff will be happy to help you complete the form over the telephone.
