Wheelchair (W/C) Reservation Request
First Name
*
Last Name
Best Contact Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State
Zip Code
Patient's Height (Approx)
*
Patient's Weight (Approx)
*
Email
example@example.com
Alternate Contact Name
W/C Dimensions (Rx)
Unite of Measurement
Inches
Cm
1) Chair Width
2) Chair Depth
3) Seat to Floor Finished
4) Foot Rest Length
5) Back Rest Height
6) Back Rest Width
7) Arm Rest Height
8) Head Rest Height
Components
Cushion
Backrest
Armrests
Footrests
Dynamic Tilt
Brake Extensions
4-point seat belt
Lap Tray
Elevating Leg Rest
Add Your Email for Exclusive Offers
example@example.com
Submit
Should be Empty: