CAERN Form

I hereby authorize the Carle Arbours Equipment Referral Network to release the following information to potential buyers/sellers of this equipment (check all that apply):

Home Phone Work Phone Fax Number E-Mail Address

By submitting this form, I understand that the Carle Arbours Equipment Referral Network will not participate in any way in the assessing of value, pricing or determining the terms of any transaction made between myself and another participant in the CAERN. Further, the CAERN is not responsible in any way for assessing the quality, durability or safety of any equipment I may purchase from another participant, and I realize that I am advised to seek guidance from health care personnel directly involved in my care when purchasing used equipment.

Note: If the piece of equipment being registered is a wheelchair, please answer the questions below.

1. Does the wheelchair recline?	Yes
2. Does the wheelchair fold?	Yes
3. Are the arm rests of the wheelchair removable?	Yes
4. Is the height of the armrests adjustable?	Yes
5. Are the leg rests of the wheelchair removable?	Yes
6. Do the leg rests of the wheelchair elevate?	Yes
7. Can you add or remove air from the tires?	Yes
8. How wide is the seat of the wheelchair?	16" 18" 20"
9. How high is the seat of the wheelchair, from the floor to the seat?	17" 19"
Other (please specify)

10. Does the wheelchair have a cushion?	Yes
a. If yes, what is the make and model? Make Model
b. If yes, how wide and how deep (front to back) is the cushion? Width Depth

11. Does the wheelchair have a special back?	Yes
a. If yes, what is the make and model? Make Model
12. Does the wheelchair have a seat belt?	Yes

13. Please indicate which, if any, of the following equipment is attached to the wheelchair:
Oxygen tank holder Left side arm trough Right side arm trough Drop seat Lap tray Left side one-half lap tray Right side one-half lap tray Wedge cushion
Other (please specify)

NOTE If a wheelchair has a special cushion, back or other attachment, please register each of these items separately if you are willing to sell them that way. Thank you.

Equipment Referral Registration