Seating and Mobility Inquiry Form

Date
MM slash DD slash YYYY
Are you a part of St. Mary’s healthcare system?(Required)
- Yes
- No
If answered YES to question above, please specify which program:
- Locomotor Training
- CHHA
- Early Ed
- MDHC
- Other
Patient Name(Required)
First Last
Date of Birth(Required)
MM slash DD slash YYYY
Gender(Required)
- Male
- Female
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Caregiver Name(Required)
Caregiver First name Caregiver Last Name
Home Phone(Required)
Cell Phone(Required)
Email(Required)
Preferred Method of Communication(Required)
- Home Phone
- Cell Phone
- Email
Does patient have insurance?(Required)
- Yes
- No
Primary Insurance?
Secondary Insurance (if applicable)?
Which of the following primary diagnoses applies to the patient:(Required)
- Cerebral Palsy
- Neurological Deficit
- Post-Surgical
- Spinal Cord injury/ Acute Flaccid Myelitis
- Genetic Disorder
Does patient have any other medical condition/s? (Please list all)
Does patient currently have any equipment?(Required)
- Yes
- No
If yes, what type of device?
- Manual Wheelchair
- Power Wheelchair
- Tilt in Space Wheelchair
- Stander
Please state reason patient is in need of a seating and mobility evaluation appointment:(Required)
- Newly Diagnosed
- Broken Chair/repair
- Grew out of current equipment
How did you hear about us?(Required)

Δ

Date
MM slash DD slash YYYY
Are you a part of St. Mary’s healthcare system?(Required)
- Yes
- No
If answered YES to question above, please specify which program:
- Locomotor Training
- CHHA
- Early Ed
- MDHC
- Other
Patient Name(Required)
First Last
Date of Birth(Required)
MM slash DD slash YYYY
Gender(Required)
- Male
- Female
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Caregiver Name(Required)
Caregiver First name Caregiver Last Name
Home Phone(Required)
Cell Phone(Required)
Email(Required)
Preferred Method of Communication(Required)
- Home Phone
- Cell Phone
- Email
Does patient have insurance?(Required)
- Yes
- No
Primary Insurance?
Secondary Insurance (if applicable)?
Which of the following primary diagnoses applies to the patient:(Required)
- Cerebral Palsy
- Neurological Deficit
- Post-Surgical
- Spinal Cord injury/ Acute Flaccid Myelitis
- Genetic Disorder
Does patient have any other medical condition/s? (Please list all)
Does patient currently have any equipment?(Required)
- Yes
- No
If yes, what type of device?
- Manual Wheelchair
- Power Wheelchair
- Tilt in Space Wheelchair
- Stander
Please state reason patient is in need of a seating and mobility evaluation appointment:(Required)
- Newly Diagnosed
- Broken Chair/repair
- Grew out of current equipment
How did you hear about us?(Required)

Δ

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(718) 281-8800 | info@stmaryskids.org

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St. Mary’s Hospital for Children

29-01 216th Street
Bayside, NY 11360
Telephone: (718) 281-8800

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Queens Borough President Helen Marshall
Early Education Center
Telephone: (718) 281-8848

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