Loading... Equipment Application Form Date Name of the person who needs the wheelchair If the Applicant a minor, name of the parent or representative E-mail Address Country Phone Number 1 Phone Number 2 Other contacts, email, whatsapp Date of Birth Sex F M Age Height Weight Diagnosis/Illness What do you use to get around? Measurements Photograph (Max 2MB) 0% Complete 1 From head to Chair 2 From shoulder to Chair 3 From knee to chair's support 4 From knee to floor 5 Hip width Clear Form
