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Application For Equipment 2

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jolleynevaeh7
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29 views2 pages

Application For Equipment 2

Uploaded by

jolleynevaeh7
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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We Share Application Form

Please print, completing each field/question as best you can for yourself or on
behalf of the patient.

Pick-Up Date:
Patient name: _______ Phone: ( )
Client Date of Birth: ___ /__ /_ Cell: ( )
Address ________
City _________________________ State Zip
How did you learn about We Care We Share? _______________________________________________
____________________________________________________________________________________

To provide our funders with the most accurate information about the people whom we serve, we ask that you please
complete the following brief questionnaire.
Have you applied for assistance for the needed equipment through insurance, Medicaid, Medicare?
YES NO
How long will you need the equipment?
Client Gender: Male Female Veteran? Yes No
Diagnosis: Cardiac Respiratory Trauma Neurological Cancer Congenital Disorder Diabetes Dementia
Ethnicity: African American Asian American American Indian Caucasian Latin American

Client Education: Elementary High School/GED College Master’s Degree


Client Income Level: ___under $25,000 $26,000 to $50,000 $51,000 to $75,000 ___ $76,000
___$100,000 __$100,000 +

Equipment on Loan:
ID# Type Equipment _____ Recorded_____
ID# Type Equipment Recorded_____
ID# Type Equipment Recorded_____
ID# Type Equipment Recorded_____
Does the equipment you received meet your (or the patient’s) needs? ___________
Were you able to get the kind of equipment you came for? ___________
Is the equipment in good condition? _______ Will the equipment help you (or the patient) feel safer? ______

Revised 9.12.18/cmr/Sharepoint
Will the equipment or supplies improve your (or the patient’s) quality of life? ________

If We Care We Share had not provided it for you, would you have had other resources? ________
Will you recommend others to use our services? __________
Other comments? __________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I acknowledge that the above-identified equipment was inspected by me, or the person responsible noted above and at the time I
received the equipment it was clean and in good condition. I agree that I will return the equipment in the same condition when
my present physical need no longer exists. I will not permit this equipment to be transferred to another person under any
circumstances, and while this equipment is in my possession, I will notify you of any change of address for me. I will not take this
equipment out of the area served by We Care, We Share. I hereby release and hold harmless We Care, We Share, its members,
agents, or employees from any claim by me, or any person acting for me or on my behalf for any loss, expense, or damage,
including but not limited to general, specific, incidental, or consequential damages, of any kind or nature whatsoever arising from
this equipment or its use. I agree that We Care, We Share, its members, agents, volunteers or employees have made no
representation of any kind whatsoever expressed or implied, to me with regard to the condition of the equipment provided or as
to the use to which the equipment is to be put. I also give We Care, We Share permission to take my photo and to use it in any
and all promotional venues.

Signature of Client/ Legal Guardian / Advocate: __________________


Date:
FOR OFFICE USE ONLY
Donation: $____________________

Date entered in database: ___________

Return Date: __________________

Initials: ____________________

Revised 9.12.18/cmr/Sharepoint

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