Request Form For Wheelchair To request a chair please answer as many of the following questions as you can: Date Type of Chair Needed (Check all that apply) Adult Pediatric Manual chair Power chair Individual in Need Address Address2 City, State, Zip Home Telephone Work Telephone Other Telephone E-mail Contact Person (if different) Address Address2 City, State, Zip Home Telephone Work Telephone Other Telephone E-mail What is needed? Approximate height and weight of individual and/or chair width needed? Height? Weight? Seat Width Needed How did you hear about us?
To request a chair please answer as many of the following questions as you can:
Date
Type of Chair Needed (Check all that apply) Adult Pediatric Manual chair Power chair
Individual in Need Address Address2 City, State, Zip
Home Telephone Work Telephone Other Telephone
E-mail
Contact Person (if different) Address Address2 City, State, Zip
What is needed?
Approximate height and weight of individual and/or chair width needed?
Height?
Weight?
Seat Width Needed
How did you hear about us?
Request Form For Wheelchair