Wheelchair Repair Form

Wheelchair Repair Form
RECIPIENT INFORMATION
Name
First NameLast Name
Medical ID
Phone number
Please enter a valid phone number.
Date of birth
MonthDayYear
Date
WHEELCHAIR INFORMATION
Model
Serial number
Miles/Hours reading
The number of months since the equipment was acquired or manufactured
Initial dispense date
MonthDayYear
Date
Name of person/company/entity who purchased wheelchair
First NameLast Name
Is this request for a modification?
YesNo
Name of manufacturer of replacement parts
What was the first concern expressed by the recipient that led to the assessment?
How did the wheelchair come into disrepair?
Please provide the service repair documentation.
Cancelof
Itemize all parts requiring replacement and their costs
CONFIRMATION
I confirm that by signing and sending this report, the information contained within it can be trusted to make an accurate assessment of whether repairs are necessary. I verify that all details provided in this document are genuine and precise.
Technician Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

RECIPIENT INFORMATION