Equipment Loan request form

The MND Association cannot use its resources to replace statutory responsibilities. In completing this application form, health and social care professionals should include supporting documentation demonstrating efforts made to secure statutory provision. In signing this application form the professional confirms every effort has been made to seek statutory and other appropriate resources.

We will not process incomplete forms. Referring professionals must ensure applications are fully completed and returned in a timely manner. Please include ethnicity according to Department of Health coding.

If you have any queries about this application process, please email support.services@mndassociation.org
1. Details of person with MND
Name*
Full name of person with MND consenting to this request
Title First Last
Date of birth:*
DD
MM
YYYY
Address* Post Code* Postcode lookup only available for UK addresses

Street Address Address Line 2 City County Postcode
Email
Telephone
Gender*
- Male
- Female
Ethnicity code:*
Place of diagnosis:
(i.e. name of hospital/care centre)
Date of diagnosis:*

2. Details of professionals
Name of requesting professional*
First Last
Job title
Address Post Code Postcode lookup only available for UK addresses

Street Address Address Line 2 City County Postcode
Email*
(Confirmation email will be sent to this address)
Telephone
Normal working hours when you can be contacted:
Contact details of a colleague who can be contacted if you are unavailable:
Name
First Last
Telephone
Email
GP's Name*
GP's address Post Code Postcode lookup only available for UK addresses

Street Address Address Line 2 City County Postcode

3. Details of Equipment Loan Request
For all equipment requests, please provide a rationale for why you are applying.

If the person with MND has already been referred to an AAC Specialist centre, please let us know.

Please note: The provision of suction units is a statutory requirement. While we are continuing to loan suction units, we are now requesting that statutory services contribute £50 towards the transport, maintenance and cleaning costs of each unit requested. Please tell us the name of the person we need to invoice for the £50 payment or send us a purchase order. This request should not delay delivery. We will continue to review the provision of suction units, along with other items that are part of our current core loan items.
For Suction units: Please tell us the name of the person we need to invoice for the £50 payment.
Items requested with details of specification:
Delivery address for equipment: Post Code Postcode lookup only available for UK addresses

Street Address Address Line 2 City County Postcode
Telephone:
Any other relevant information:

4. Funding by statutory agencies or others
Please give detail of what attempts have been made to secure the equipment/funding from the statutory services:
Reason why this need cannot be met by statutory services. For all equipment requests, please provide a rationale for why you are applying:
If the equipment or service IS available from statutory services but there is a waiting list please state the date the equipment or service is likely to be available:
DD
MM
YYYY
Details of other charities or organisations that have been approached for funding. If the person with MND has already been referred to an AAC Specialist centre, please let us know:

5. Any other information relevant to the application
Please give details...
6. Statement by the referring professional
If this application is approved, I understand that, unless otherwise agreed with the support services team:
- Where appropriate, it is my responsibility to continue to pursue funding from statutory services
- It is my responsibility to monitor and assess the ongoing needs of the person with MND in relation to this application.
- It is my responsibility to notify the relevant statutory service that the MND Association has provided equipment loan services to a person with MND
- Should I leave my current post, I will notify the MND Association of the name of the professional who has taken on the responsibility for ongoing communication and liaison with the MND Association
- I will monitor suitability, provide any necessary instruction, and will notify you when equipment is no longer needed.
Please tick the boxes below to confirm you have read the statement above
- I agree to everything stated in the form above
- I have read the MND Association Privacy Policy (Opens in a new window)
Date*
DD
MM
YYYY

1. Details of person with MND