ENQUIRY TYPE

CommercialBusinessOrganisationPrivate

NAME:

Name: (Organisation, Business etc.)

ADDRESS:

PHONE:

FAX:

MOBILE:

EMAIL (Required):

WHEELCHAIR USER:

AGE:

CHAIR TYPE:

ManualElectric

BUDGET: (Approx.)

FUNDING BY:

NUMBER OF WHEELCHAIR POSITIONS:

ACCESS ENTRY PREFERENCE:

RearSide

PERSONS WEIGHT: (kg)

SEATED HEIGHT: (mm)

CHAIR WEIGHT: (kg)

CHAIR LENGTH (overall): (mm)

CHAIR WIDTH (overall): (mm)

POWER CONTROLS:

LeftRight

SLIDE TRANSFER:

YESNO

SELF DRIVE:

YESNO

ADDITIONAL POSTURAL SUPPORT:

YESNO

HEAD REST:

YESNO

TILT FUNCTION:

YESNO

RESTRAINT ATTACH:

YESNO

ADDITIONAL STOWAGE SPACE:

EXTRA SEATING REQUIREMENTS:

OTHER RELEVANT INFORMATION AND SPECIAL NEEDS/REQUESTS:

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