Required fields are denoted with an asterisk(*).
*Serial Number
The serial number is located on the cushion inside of the cover. See detail image at right.
*Part Number
The part number is located on the cushion inside of the cover. See detail image at right.
*Date Purchased
*Purchased From
*Recommended by
-- Make a Selection -- Doctor Therapist Friend Dealer Advertisement Other
*Customer First Name
*Customer Last Name
*Address
*City
*State
*Zip
Phone
Email
*Country
-- Select Country -- United States Canada Mexico
Sex
Date of Birth
Weight
-- Select Weight -- 50 lbs 60 lbs 70 lbs 80 lbs 90 lbs 100 lbs 110 lbs 120 lbs 130 lbs 140 lbs 150 lbs 160 lbs 170 lbs 180 lbs 190 lbs 200 lbs 210 lbs 220 lbs 230 lbs 240 lbs 250 lbs 260 lbs 270 lbs 280 lbs 290 lbs 300 lbs Over 300 lbs
Height
-- Select Height -- 3' 0" 3' 1" 3' 2" 3' 3" 3' 4" 3' 5" 3' 6" 3' 7" 3' 8" 3' 9" 3' 10" 3' 11" 4' 0" 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 0" 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" Over 6' 6"
Injury/Diagnosis
-- Select Injury/Diagnosis -- Amputation Cerebral Palsy Cerebral Vascular Accident Congenital Multiple Sclerosis Orthopedic Paraplegic Parkinson Polio Quadriplegic Tetraplegic Traumatic Brain Injury Other Brain Injury Other Cardio/Pulmanary Other Neurological Other Injury/Diagnosis
Date of Onset
Pressure Ulcer History
-- Select Pressure Ulcer Status -- No Pressure Ulcer Past Pressure Ulcer Current Pressure Ulcer
Type of Wheelchair
Chair Manufacturer
-- Select Manufacturer -- Colors Ernest-Jennings Invacare Küschall Quickie-Sunrise Scooter Ti-Lite Other
Chair Size
-- Select Chair Size -- 12" x 12" 12" x 14" 14" x 14" 14" x 16" 16" x 16" 16" x 18" 16" x 20" 17" x 17" 18" x 16" 18" x 18" 18" x 20" 20" x 16" 20" x 18" 20" x 20" Other Size
What was your previously used cushion or back system?
-- Select Previous System -- None Jay Roho Supracore FloFit Huntliegh Avanti Freedom Designs Action Foam/Egg Crate Custom Molded Don't Know
Transfers Per Day
-- Select Transfers -- 1 2 3 4 5 6 7 8 9 10 more than 10 don't know
Time in Chair Per Day
-- Select Time Per Day -- 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12 hours 13 hours 14 hours Over 14 hours
Are you a Sports Participant? Basketball Biking Dancing Horseback Riding Racing Rugby Skiing Softball Tennis Other
Reason(s) for Purchasing VARILITE Adjustability Aesthetics Comfort Pressure Distribution Positioning Weight Temperature Control Maintenance Price Recommended Stability Other
Suggestions for Improvements / New Products / Accessories:
Other Comments:
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