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  
     
  Mini Wheelchair
Strut Size
 








 
  Mini Wheelchair
Wheel Size:
 





 



 
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
Dog   To prove you are a person (not a spambot) Please answer the question with a 3 letter word.
What kind of animal is this?