There is no better compliment than a referral and we want to show our appreciation. Please fill out the form below with both your contact information and your friend’s. If your friend becomes a new customer* we will send you both a $50 gift card to thank you for choosing Lifeway.

* Applies to a new customer 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. Purchases involving governmental funding are not eligible for this program

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 Information

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

Submitting Details