REMAP can help find a solution to your client’s problem. Please complete this form and hand it to your representative on REMAP’s monthly Case Meeting. A REMAP Panel member will contact you Priorto any meeting with your client to discuss your prescription, the risks involved both in visits and subsequent use of the final device. Panel members are well aware that virtually every device made will fall within the Medical Devices Directive (1998)

Date ..........................    Case Title ..............................................              Case Number ........................

Referrer ......................................................         Job Description ...........................................................

Work Base (Full address please)
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Postcode ................  Tel............................... email .....................................................

Client’s Name  ............................................           Age Group     0-18          19-65            65+

Address (Full address please including postcode)

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Postcode ................  Tel............................... email ...................................................

Problem Experienced by your Client