I can confirm that I have gained permission from the tenant to provide details of their illness/disability to Midland Heart, as failure to provide information may result in their case not being supported.

Medical Professional Information

Applicant details

Property Information

Functional abilities of applicant / medical condition

Please provide detailed information

Options considered / rejected

Please provide detailed information, the application may be delayed if all alternative equipment/adaptation provision have not been considered and reasons why not appropriate detailed below. For example - all applications for level access showers will not be considered unless bathing equipment and alternative solutions have been assessed and reasons why not detailed below.

Preferred solution

Please provide detailed information