Seating and Mobility Inquiry Form

Date
Are you a part of St. Mary’s healthcare system?(Required)
- Yes
- No
If answered YES to question above, please specify which program:
- Locomotor Training
- CHHA
- Early Ed
- MDHC
- Other
Patient Name(Required)
First Last
Date of Birth(Required)
Gender(Required)
- Male
- Female
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Caregiver Name(Required)
Caregiver First name Caregiver Last Name
Home Phone(Required)
Cell Phone(Required)
Email(Required)
Preferred Method of Communication(Required)
- Home Phone
- Cell Phone
- Email
Does patient have insurance?(Required)
- Yes
- No
Primary Insurance?
Secondary Insurance (if applicable)?
Which of the following primary diagnoses applies to the patient:(Required)
- Cerebral Palsy
- Neurological Deficit
- Post-Surgical
- Spinal Cord injury/ Acute Flaccid Myelitis
- Genetic Disorder
Does patient have any other medical condition/s? (Please list all)
Does patient currently have any equipment?(Required)
- Yes
- No
If yes, what type of device?
- Manual Wheelchair
- Power Wheelchair
- Tilt in Space Wheelchair
- Stander
Please state reason patient is in need of a seating and mobility evaluation appointment:(Required)
- Newly Diagnosed
- Broken Chair/repair
- Grew out of current equipment
How did you hear about us?(Required)

Δ

Date
Are you a part of St. Mary’s healthcare system?(Required)
- Yes
- No
If answered YES to question above, please specify which program:
- Locomotor Training
- CHHA
- Early Ed
- MDHC
- Other
Patient Name(Required)
First Last
Date of Birth(Required)
Gender(Required)
- Male
- Female
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Caregiver Name(Required)
Caregiver First name Caregiver Last Name
Home Phone(Required)
Cell Phone(Required)
Email(Required)
Preferred Method of Communication(Required)
- Home Phone
- Cell Phone
- Email
Does patient have insurance?(Required)
- Yes
- No
Primary Insurance?
Secondary Insurance (if applicable)?
Which of the following primary diagnoses applies to the patient:(Required)
- Cerebral Palsy
- Neurological Deficit
- Post-Surgical
- Spinal Cord injury/ Acute Flaccid Myelitis
- Genetic Disorder
Does patient have any other medical condition/s? (Please list all)
Does patient currently have any equipment?(Required)
- Yes
- No
If yes, what type of device?
- Manual Wheelchair
- Power Wheelchair
- Tilt in Space Wheelchair
- Stander
Please state reason patient is in need of a seating and mobility evaluation appointment:(Required)
- Newly Diagnosed
- Broken Chair/repair
- Grew out of current equipment
How did you hear about us?(Required)

Δ

Contact Us

(718) 281-8800 | info@stmaryskids.org

Subscribe to Our Newsletter

St. Mary’s Hospital for Children

29-01 216th Street
Bayside, NY 11360
Telephone: (718) 281-8800

St. Mary’s Preschool

Queens Borough President Helen Marshall
Early Education Center
Telephone: (718) 281-8848

Center for Pediatric Feeding Disorders

Telephone: (718) 281-8541

St. Mary's Home Care

333 Earle Ovington Blvd. Suite 600
Uniondale, NY 115533
Telephone: 718.281. 8600

ABA at St. Mary's Kids/Extraordinary Peds

Telephone: (516) 621-2681

CMS Overall Rating: 5 | Health Inspection Rating: 5
Staffing Rating: 5 | QM Rating: 5

Visitor Info
Programs & Services
For Families
Privacy
Corporate Compliance
Corporate Hotline
Employees & Contractors
Pandemic Emergency Plan
Privacy Policy
Request Medical Records
Transparency in Coverage Medical

Hospital Resources

Access the resources and information you need to be a strong advocate for a child with a complex medical condition.

Learn More

Center for Innovation

The Mission of St. Mary's Center of Innovation is to improve the health and quality of life for children with special healthcare needs and their families through the development, acceleration, and research of innovative processes, programs and technologies.

Learn More

Close Menu

About
Programs & Services
For Families
- Get To Know Us
- Your Stay at St. Mary’s
Ways To Give
Why Give
Donate

Visitor Info
Contact & Locations
Careers
Events
News
Blog
English Link[glt language=”English” label=”English”]
Search

Close Modal

Secret Link