Client / Chair Information Form for Wheeleez™ Wheelchair Beach Conversion Kit

In order to help you choose the right conversion kit for your chair, please provide the following. We’ll review it and contact you.

Asterisk (*) indicates that the field is “required” and you won’t be able to submit the form without filling that field.

Company
This field is for validation purposes and should be left unchanged.
Client Information:
Client Name:
First Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email:*
Phone:
Chair Rider Information:
Chair Rider Name:*
First Last
Height:*
Weight:*
Gender:
Anatomical Support Requirements:
Special Notes:
Wheelchair Information:
Manufacturer Name:
Model:
Year:
Rear Wheel Diameter:
Frame Tubing Diameter:
Frame Width (outside to outside):
Is this unit the:
- Primary chair
- Secondary chair
Pictures Required:
a) Rear angle (from directly behind chair):*
Accepted file types: jpg, jpeg, png, gif.
b) Front angle (from directly in front of chair):*
Accepted file types: jpg, jpeg, png, gif.
c) Side angle, rear wheel removed:*
Accepted file types: jpg, jpeg, png, gif.
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