SERVICE REQUEST FORM
Date:
Place where wheelchair was purchased:
Customer Name:
Customer Mailing Address:
Customer Email Address:
Customer Phone Number:
Best Time to Call (Including Time Zone)
WHEELCHAIR INFORMATION
Select One
Regular Wheelchair
Strut Size
Mini Wheelchair
Strut Size
6
9
12
15
6
9
11
Regular Wheelchair
Wheel Size
Mini Wheelchair
Wheel Size:
4
8
12
16
4
8
Breed of dog:
Weight of dog:
Fold of flank measurement:
(?)
Problem in detail:
Can you send us a photo of the problem?
See email address below
Nancy@handicappedpets.com
To prove you are a person (not a spambot) Please answer the question with a 3 letter word.
What kind of animal is this?