The Panel will be pleased to seek a solution to your client’s problem, one for which a commercial solution is not available. As the prescriber you are responsible for advising of any risk to a volunteer or  your client. A Panel member will contact you to arrange as first visit when the problem can be explained and a solution discussed. Please arrange at this first meeting whether future visits need be accompanied. Our volunteers are well aware of safety issues and will advise of any risks arising from the use of a device supplied but it is nevertheless essential that you  assess the device and approve it matches your prescription.  The device  made or adapted will be treated as coming within the Medical Devices Directive (1998) unless specifically indicated otherwise and has to be prescribed  by Healthcare Professional.  It will be for the exclusive use of a named client.

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

Referrer (giving  position held and full postal address)



Postcode ......................                Phone Number  .....................................    Email  ..........................................

Client’s Name (giving full postal address)



Postcode ......................                 Phone Number ....................................

Age Group                0-18               19-65             65+       

Problem Experienced (continue overleaf  if necessary)









Suggested Solution






Please send completed )         1. Sue Marshall (OT)  York Social Services 30 York Road Acomb
 form  internally to      )        2.  Mona Manan OT  NeurosciencesYork Hospital
Or by Royal Mail to        K Wood   9 The Avenue   Clifton  YORK  YO30 6AS