Give and receive! Recommend Lifeway and earn rewards!

There is no better compliment than when we get a referral and we want to show our appreciation. If the referral becomes a customer*, we will send you both a $50 gift card to thank you for choosing Lifeway Mobility.

Please fill out the form below with both your contact information and information for the person you are referring.

* Applies to purchase of stairlifts, installed modular ramps, accessible shower/bath systems, and lifts/elevators. Must be eligible to participate. Certain professionals such as clinicians or government employees may still make a referral but are not eligible for gift cards or other compensation from Lifeway Mobility.

Who is Referring the New Customer?

Referrer's First Name*

Referrer's Last Name*

Company Name*

Referrer's State*
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY

Referrer's Phone Number*

Referrer's Email*

Are you a Clinician*
Yes No

I understand as a clinician I am not eligible for a gift card but would still like to make this referral.

Are you a Government Employee*
Yes No

I understand as a government employee that I am not eligible for a gift card but would still like to make this referral.

New Customer Info

Referral's First Name*

Referral's Last Name*

Referral's Email

Referral's Phone

Referral's Address (of installation)

Referral's City (of installation)

Referral's State*
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY

Referral's Postal Code

Is Referral Eligible for a Waiver?
 Yes   No

Product / Service of Interest
 Ramp
 Stair Lift
 Bathroom Safety
 Wheelchair Lift / Elevator
 Transfer / Ceiling Lift
 Ramp

Comments

Submitting Details