Repair Service Request Form
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
If we've billed insurance for you before, please list your current Primary Care Provider/Doctor (PCP):
Your Location:
Maui
Kauai
Oahu
Big Island
Type of Equipment
*
Manual Wheelchair
Scooter
Power Wheelchair
Custom Bathroom Safety Equipment
Other
Please specify the repairs or maintenance requested:
*
Additional Comment and Questions:
If you have any photos to upload to help our technicians with this service request, please do so here:
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