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Home » Patient Profiler

Patient Profiler

Convaid, Inc.
P.O. Box 4209
Palos Verdes, CA 90274
888-CONVAID
(888) 266-8243
(310) 618-0111
(310) 618-2166 (fax)

Please answer as many questions as possible, so we can better assist you with your selection.

Required *

Contact Information:
Name *
Telephone Number
Country
Email *
Relationship to Wheelchair User * Doctor
Physician
Dealer
Physical Therapist
Parent
Caregiver
 
Wheelchair User Information
Name
Ages (Years & Months)
Sex
 
Is the user able to sit upright in a wheelchair without assistance?
Yes No Don't Know
 
Does the user need to change position often?
Yes No Don't Know
 
What will the chair be used for? (Check all that apply)
"All-day" seating
Only at school

Transportation in
 
How tall is the user?
Feet & Inches Meters Don't Know
 
What is the user's seat width?
Feet & Inches cm Don't Know
 
What is the user's weight?
Lbs KG Don't Know
 
Where will the chair be used? (Check all that apply)
City
Countryside
Park
Home
School
Snow
 
What type of climate will the chair be used in?
 
What is the user's favorite color?
 
What type of insurance does the user have?
 
Additional Details and Special Requests:
 
Validation Code *  required
 
Wheelchairs | Pediatric Wheelchairs | Adult Wheelchairs | Wheelchair Accessories
Convaid Lightweight, Compact-Folding Wheelchairs for Pediatrics & Adults
© 2010 Convaid | P.O. Box 4209 | Palos Verdes, California 90274 USA
Toll Free: 888-CONVAID (266-8243) | Phone: (310) 618-0111 | Fax: (310) 618-2166
All Convaid prices are listed in USD and are only applicable within the USA. The Convaid models shown are USA based and may vary by country.
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