Scooter/electric wheelchair part 1 medical questionnaire - RAP

Form ID
For providers
General Practitioner

A medical questionnaire completed by the LMO(GP). This is part 1 of a 2-part process (see D1325 for Part 2) and outlines the eligibility criteria and important clinical aspects to be considered prior to a veteran being assessed for an electric mobility aid.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
Form (PDF or Word)