electric wheel chair, electric wheel chairs
electric wheelchair, electric wheelchair
Home | Products | Insurance Qualification | Cost | Submit Info

Call today to see if you qualify—toll-free (888) 298-0661

Get Information about an Electric Wheelchair

Often we find that information is gathered on behalf of someone who is in need of an electric wheelchair. We work with this person, whether a friend or relative, to get the process going. Please fill out the form and one of our Customer Support Professional will get in touch with you. We would also like to send you a FREE brochure.

If you feel like you know enough to have us contact your doctor and get the ball rolling, please fill out our qualification form.

Patient Information
Name:
Primary Insurance:
(i.e., Medicare)
Street:
Secondary Insurance:
(if applicable)
City:
    
State:
  
ZIP:
  
Email:
  
Phone number:
( If you are submitting on behalf of the patient and wish to be contacted, please fill out the information below )
Your Name:
Phone:
Street:
Best time to call:
City:
Your email address:
State:
How did you hear about us:
ZIP:
    
Questions / Comments:
   
 
We will not sell, lease or give away any of your contact information. All information gathered is for the purpose of getting in touch with you.

 
 
 
 

Home | Products | Insurance Qualification | Cost | Submit Info | Email Us | Site Map

Toll free: (888) 298-0661
Email: info@123electricwheelchair.com

Design by Green Chair Marketing Group, Denver web design company