The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

AqGuuqugKLBuEDZDZepbsvRwRs8VjbMHf2kMKZwj

Intake Form - Special Needs Adaptive Car Seat Assessment

This form must be completed by a referring agency/organization.

Please Note: The purpose of a special needs adaptive car seat assessment is to determine what type of adaptive car seat will best support the patient while transporting them in a vehicle. This service does not equip the patient with an adaptive car seat. An assessment considers multiple factors related to the patients size and weight, current condition, limitations, future complexities, primary vehicle size and type, and more.

At the conclusion of the assessment a recommendation will be provided to the caregiver regarding the best adapative device(s) that will support and restrain the patient safely in a vehicle. This information is most useful when assisting a caregiver with durable medical equipment providers and/or insurance.

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