FOX Medical | Hospital Equipment for the Home

Wheelchair Evaluation Form

Fields marked with a red dot ( *) are required.

Required Information
  3.  (xxx) xxx-xxxx
Personal Information
  5.  [5 digits]

  9. (See Diagram Below)

  19. Measuring Positions
  20. With

  21. With

  22. How far?






  31. Where?

  32. Where?

 

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An Independent Company for Independent Living