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Request a Collection

Request a Collection of a MOTOmed unit

To request the collection of a MOTOmed unit then please complete this form and click on Submit. Please do not provide any detail on the Clients condition or medical history. All information supplied is encrypted once submitted and is stored securely in full compliance with GDPR guidelines.

Please note: if the client has a unit on relocation then Lyncare will automatically arrange collection at the end of the scheduled relocation period. This collection request is only for where client circumstances have changed and the unit is to be collected early or from extended loan.

An Eircode is the most accurate way of providing an address so please endeavour to supply one for each new client.

 

It is imperative that at least one active telephone number is supplied for every client, either a direct number for the client and/or for a carer. The more contact numbers provided the easier it will be for Lyncare to make contact. Any clients submitted without an active telephone number will be rejected.

 

 

* Fields marked with an asterisk are mandatory.

    Client Details














    Carer Details








    Prescriber Details






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