Patient Information

Name of Person in need: (required)

Contact Email Address: (required)

Address 1:

Address 2:

City:

State:(required)
Alabama  Alaska  Alberta  Arizona  Arkansas  British Columbia  California  Colorado  Connecticut  Delaware  District of Columbia  Florida  Georgia  Hawaii  Idaho  Illinois  Indiana  Iowa  Kansas  Kentucky  Louisiana  Maine  Manitoba  Maryland  Massachusetts  Michigan  Minnesota  Mississippi  Missouri  Montana  Nebraska  Nevada  New Brunswick  New Hampshire  New Jersey  New Mexico  New York  Newfoundland  North Carolina  North Dakota  Nova Scotia  Ohio  Oklahoma  Ontario  Oregon  Pennsylvania  Quebec  Puerto Rico  Rhode Island  Saskatchewan  South Carolina  South Dakota  Tennessee  Texas  Utah  Vermont  Virginia  Washington  West Virginia  Wisconsin  Wyoming  Out of country

Zip:

Shipping address if different:

Address 2:

Phone:
  Ext:  

Patient Email Address:

Has Insurance been applied for and denied:
choose Yes or No Yes No

Current Housing Arrangement:
Choose Private Home Hospital Institution

Physical Information
The following information, about the patient requesting the wheelchair, will help us provide the correct style and size

Date of Birth:

Height:

Weight:

Describe type and degree of mobility impairment:

Is the Patient currently in a wheelchair:
choose Yes or No Yes No

If yes, describe make and model:

Wheelchair Size:
Unknown Adult Pediatric Bariatric

Wheelchair Seat Width

Wheelchair Seat Depth

Contact Information
If you are a relative, friend, healthcare professional, etc., filling out the Request Form, the following information is required where applicable:

Contact Name: (Required)

Contact Phone: (required)
  Ext:  

Health Professional or Agency?:
choose Yes or No Yes No

If yes,the following information is required:

Name of the Health Care Professional or Agency:

Type of Agency:

Complete Address:

Other Comments:

Verification Question: (required)
Which of the following is an animal?
Plant, Flower, Sunshine, Dog

Electronic Signature
By checking this box, you agreed that I have requested that a reconditioned or new wheelchair provided to me by Chariots (the “Wheelchair”). While Chariots believes the Wheelchair to be in sound condition, it cannot represent or warranty that to be the case, and I agree, by signing this release, that I will not hold Chariots responsible for an injury as a result of any defect in the Wheelchair. Now, therefore, in consideration of Chariots’ provision of the Wheelchair to Me, the sufficiency of which consideration is acknowledged by Me, and intending to be legally bound, I agree as follows: I hereby release and forever discharge Chariots, its officers, directors, volunteers and their successors and assigns, from any and all “Claims” (as defined in Section 2 below) which I ever had, now has, or hereinafter can, shall or may have against Chariots, its officers, directors, volunteers and their successors and assigns arising out of, in connection with or because of, my use of the Wheelchair. For the purposes of this Release, the term “Claims” means claims, actions, causes of action, suits, debts, accountings, accounts, agreements, promises, damages, liabilities, and obligations of any nature, kind or description whatsoever, known or unknown, at law or in equity. This Release shall bind and inure to the benefit of each party and his or its respective executors, administrators, personal representatives, heirs, successors and assigns. The words "I" and "Me", together with any pronoun used in connection therewith in any form, shall include the singular, plural, masculine, feminine and neuter, as the context may require. Whenever used, the singular number shall include the plural and the plural the singular.

I have read the above statement and agree I do not agree to the above statement.

Date that you agreed to the above statement: