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Parts & Repair Submission Form

All questions are mandatory in order to submit form, with the exception of the warranty question and pictures.

Required Fields Marked with *
Account Name: *
Account Number: *
Contact Name: *
Contact Phone Number: *
Contact Email: *
Serial Number: *
Describe the issue: *
(Please give a detailed description in order to better service your product)
How did the part break?: *
Is this part covered under warranty?: Yes No
 
Please attach a minimum of two pictures:
Picture 1
Picture 2
Picture 3
Picture 4
Privacy is extremely important to Convaid. Your personal information will be kept confidential and will only be used to send you information about Convaid, its products and services.
 required
 
Convaid Lightweight, Compact-Folding Wheelchairs for Pediatrics & Adults
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