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.

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):*
b) Front angle (from directly in front of chair):*
c) Side angle, rear wheel removed:*
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