FREE Prism Freeway Shower Chair Home Assessment
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Phone Number
*
-
Area Cide
Phone Number
E-mail
*
example@example.com
Shower Chair you need an assessment for
*
Please Select
Freeway T40
Freeway T50
Freeway T60
Freeway T70
Freeway T80
Freeway T100
Other
Do you need the chair to go over a Geberit or Clos-o-Mat?
*
Please Select
Yes
No
Do you need side access?
*
Please Select
No
Yes
Do you need tilt-in-space
*
Please Select
Yes
No
If you are replacing an existing Freeway Chair please supply serial no. starting with CHF (this will be found on the frame which may be under cushion)
Anything the assessor needs to be aware of pre visit?
Is there parking for assessor
*
Yes
No
Maybe
Submit
Should be Empty: