Self Survey form
Measurement A
*
From top nose to floor
Measurement B
*
From top nose to end of wall or door frame
Measurement C
*
Between one step diagonally
Measurement D
*
From bottom nose to end of wall or door frame
Measurement E
*
Width of stairs
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Looking up the stairs, which side of the stairs would the stairlift fit
*
Please Select
Left
Right
Amount of steps? (including the landing)
*
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Image 1
*
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Image 2
*
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Image 3
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Image 4
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Title
*
Please Select
Mr
Mrs
Miss
Ms
Dr
Users name
*
First Name
Last Name
Installaton address
*
Street Address
Street Address Line 2
City
County
Post Code
Customer Email
*
example@example.com
Contact phone number
*
-
Area Code
Phone Number
Users weight
*
Please Select
4 Stone / 25Kg
5 Stone / 32Kg
6 Stone / 38Kg
7 Stone / 44Kg
8 Stone / 50Kg
9 Stone / 57Kg
10 Stone / 63Kg
11 Stone / 70Kg
12 Stone / 76Kg
13 Stone / 82Kg
14 Stone / 89Kg
15 Stone / 95Kg
16 Stone / 101Kg
17 Stone / 108Kg
18 Stone / 114Kg
19 Stone / 120Kg
20 Stone / 127Kg
21 Stone / 133Kg
22 Stone / 140Kg
Any other information about the user or stairs?
*
Submit
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