Request for Service

Please fill out the appropriate fields below to request for service for your accessibility equipment (stair lift, wheelchair lift, or home elevator).

(* Denotes Required Fields)

Contact Information
Payer Type: *	Private Pay 3rd Party
First Name: *
Last Name: *
Name of User (If submitting for patient, family or friend):
Phone Number: *
E-mail Address: *
Address: *
Product Type: *	Stair Lift Wheelchair Lift (Vertical Platform Lift) Home Elevator Other
Preferred Method of Contact: *	Phone Email Text Message
Briefly Describe Issue with Lift or Elevator: