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Wheelchair Assessment Form

Please complete and submit the simple form below to tell us about the wheelchair and occupant.

(please confirm your full name) e.g. Mr Robert Jones
(please confirm your best contact phone number)

About the wheelchair & occupant

(please confirm the overall length from the rearmost point of the wheelchair to the tip of the toes of the wheelchair occupant) typically 800 to 1400 (numbers only please)
(please enter the relaxed seated height of the wheelchair occupant) typically 900 to 1600 (numbers only please)
(please enter the overall low level width of the wheelchair) typically 500 to 800
(please confirm the maximum ground clearance of the foot pedestals) typically 60 to 300 (numbers only please)
(please let us know any other relevant information)