Let’s talk about your Wheelchair! Please enable JavaScript in your browser to complete this form.Name *Phone NumberLocation *Current Wheelchair Model Name *Type of Ailment *Spinal CordPolioCerebral PlasseyOthersReason to buy current wheelchair *Price of Current Wheelchair *Maneuverability of the wheelchair Selected Value: 0 Rate on a scale of 0 to 5. 0 means hard to move and 5 means easiest to moveRate your wheelchair safety Selected Value: 0 Rate in a 0 to 5 scale. 0 means poor safety and 5 means Best safetyRate the comfort level of your wheelchair Selected Value: 0 Rate on a scale of 0 to 5. 0 means No comfort and 5 means Most comfortableProblems in current wheelchair ( If any)One Feature that you would like to improve in your current wheelchair (If any)How do you Repair your wheelchair *Please mention ‘NO’ if you don’t service your wheelchairOne wheelchair that you feel is best and why?Do you use standing wheelchairYesNoSubmit
