Bailey Built Wheelchair Order Form

Wheelchair Order Form
Base Model
Base Model Choice*
Included with All-Terrain Base Model:
- 350-watt powered wheel set
- Handcrafted rigid aluminum frame
  - Built to your size
  - Forward folding backrest mount
  - Aluminum seat pan and clothing guards
  - Anti-tipper assembly
  - 1.5” standard seating dump
- Joystick Controller
  - Driving light
  - USB A and C ports
- Armrests
- Lithium Ion Battery
- Height-adjustable rigid footplate
- All-Terrain front casters assembly
Included with Junior Base Model:
- 350-watt powered wheel set
- Handcrafted rigid aluminum frame
  - Built to your size
  - Built to adjust as you grow (up to 10" total leg growth)
  - Forward folding backrest mount
  - Aluminum seat pan and clothing guards
  - Anti-tipper assembly
  - 1.5” standard seating dump
- Joystick Controller
  - Driving light
  - USB A and C ports
- Armrests
- Lithium Ion Battery
- Height-adjustable rigid footplate
- All-Terrain front casters assembly
Included with Every Day Base Model:
- 350-watt powered wheel set
- Handcrafted rigid aluminum frame
  - Built to your size
  - Forward folding backrest mount
  - Aluminum seat pan and clothing guards
  - Anti-tipper assembly
  - 1.5” standard seating dump
- Joystick Controller
  - Driving light
  - USB A and C ports
- Armrests
- Lithium Ion Battery
- Height-adjustable rigid footplate
- Every Day front casters assembly
Included with Dual Sport Base Model:
- 350-watt powered wheel set
- Handcrafted rigid aluminum frame
  - Built to your size
  - Forward folding backrest mount
  - Aluminum seat pan and clothing guards
  - Anti-tipper assembly
  - 1.5” standard seating dump
- Joystick Controller
  - Driving light
  - USB A and C ports
- Armrests
- Lithium Ion Battery
- Height-adjustable rigid footplate
- All-Terrain front casters assembly
- Every Day front casters assembly

All-Terrain Power Wheelchair Tire Size (Included with Base Model)*
Dual Sport Power Wheelchair Tire Size (Included with Base Model)*
Junior Power Wheelchair Tire Size (Included with Base Model)*
Everyday Power Wheelchair Tire Size (Included with Base Model)*
Would you like Tannus Inserts?

Yes (+$144)No
Armrests (Included with Base Model)*
Joystick Location*

Left HandRight Hand
Total Wheelchair Price

Back Rest
Back Rest Selection*
Aluminum Back Rest Height
Aluminum Back Rest Contour*
Carbon Fiber Back Rest Height*
Carbon Fiber Back Rest Contour*
Would you like Lateral Trunk Supports?*

Yes (+$716)No
*Shown with optional headrest and lateral trunk supports.
Junior Back Rest Selection*
Total Wheelchair Price

Seat Cushion
Seat Cushion Selection (Make a selection to see cushion details)*
Total Wheelchair Price

Frame Styling
Please provide your Frame Color choice here:*
Color options can be found at this website:
Check this box if you are undecided on your color choice at this time.

Undecided
Please provide vinyl wrap choice to be applied to clothing guards:*
Vinyl options can be found at this website:
Check this box if you are undecided or don't want vinyl wrapped clothing guards.

UndecidedNo vinyl wrap please

Measurements
Please provide the following information for whom this chair is being built for:*
Please provide measurements based on the diagram above.*
If you'd like to provide your measurements later, please check this box.

I'd like to provide measurements at a later time.
Please add any additional notes here:

Shipping Options
Please Select Shipping Preference*

Pick-UP (We are located in Wildomar, CA)Domestic Delivery -- United States (Lower 48 States) -- ($900)International Delivery, Hawaii, or Alaska -- (Determined at time of shipment)*
*If applicable, import taxes and fees will be due at time of delivery.

Contact Information
Client Name*

First NameLast Name
Buyer's Name*

First NameLast Name
Email*

Confirmation EmailPlease confirm email entry.
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there anything else you'd like to share with us pertaining to this build quote?
How did you hear about Bailey Built Wheelchairs?

InstagamFacebookGoogle SearchFriend or Family MemberOther
Total Wheelchair Price
Would you like to pay for this wheelchair now ?*

YesNo
PAY NOW -- Total Price

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Would you like our partners at SupportNow to help you with fundraising and grant opportunities?*

YesNo
Learn more about SupportNow here:
Signature*

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I agree to proceed with the above quoted build and understand that there are no refunds for this purchase. I understand that once payment is made, the build will begin production. I have reviewed and approved all details and measurements on this quote. I understand details and measurements on this quote cannot be changed once build begins. I understand the Bailey Built Wheelchair I am purchasing is not a medical device. understand and agree that Bailey Built Wheelchairs, affiliates, and employees are not responsible or liable for any injuries, property damage, personal damage, or death that could occur while using a Bailey Built wheelchair. The pricing on this quote is valid 30 days from the original quote date.
Quote Number
If you would like to complete this quote and purchase your wheelchair, please click the "Submit" button below.

By sumbitting this form, you are giving Bailey Built Wheelchairs permission to contact you to discuss all final options for your wheelchair.
Should be Empty:

Wheelchair Order Form

Base Model

Back Rest

Seat Cushion

Custom Add-Ons

Frame Styling

Measurements

Shipping Options

Contact Information

Learn more about SupportNow here:

If you would like to complete this quote and purchase your wheelchair, please click the "Submit" button below.