Wheelchair Seat Belt Consent Form

Wheelchair User Full Name

First NameMiddle NameLast Name

Wheelchair User Date of Birth

Date

Preferred Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Email Address

example@example.com

Parent/Guardian or Caregiver Full Name

First NameMiddle NameLast Name

Relationship to Wheelchair User

Wheelchair Type

Primary Use Setting

Wheelchair Make and Model

Approximate Seat Width or Fit Information

Posture or Positioning Support Used

Relevant Mobility or Seating Needs Affecting Seat-Belt Use

Seat Belt Type

Installed By

How Often It Will Be Used

Other

Can the User Fasten and Unfasten It Independently?

Fit Instructions and Special Positioning Notes

Health, comfort, or safety concerns relevant to seat-belt use

Explain any contraindications, precautions, or other safety notes

Should the user stop use and contact the responsible clinician or facility if discomfort, skin redness, breathing difficulty, or other problems occur?

Additional comments about comfort, skin integrity, breathing, pain, or safety

Wheelchair Seat Belt Consent and Acknowledgement

Consent Declaration

Printed Name

First NameLast Name

Signing Role / Relationship

Signature

Date Signed

Date

Wheelchair Seat Belt Consent Form

User and Representative Information

Mobility and Wheelchair Details

Seat Belt Use and Fit Information

Health, Comfort, and Safety Considerations

Consent Acknowledgement and Signature