Pediatric Wheelchair Request Form
Use this form to request a pediatric wheelchair and share the child’s information, contact details, size needs, and any special mobility requirements.
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Age or Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis or Mobility Condition
*
Caregiver / Contact Information
Parent / Guardian Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Guardian
Foster Parent
Grandparent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Wheelchair Request Details
Type of Pediatric Wheelchair Needed
*
Manual wheelchair
Power wheelchair
Stroller-style wheelchair
Specialty / adaptive wheelchair
Other
Request Type
*
Please Select
New request
Replacement
Upgrade
Temporary loaner
Other
Special Features Needed
Lightweight frame
Reclining back
Adjustable footrests
Transit-ready design
Foldable frame
Height-adjustable handles
Padded seating
Anti-tip support
Other
Sizing and Mobility Needs
Child Height (cm)
*
Child Weight (kg)
*
Delivery / Notes
Preferred delivery or pickup method
*
Home delivery
Clinic pickup
School delivery
Other
Preferred follow-up time window
Hour Minutes
AM
PM
AM/PM Option
Additional notes
Submit Request
Should be Empty: