Request a Wheelchair
  • To request a wheelchair, please complete the following on-line request form.
  • Please remember to complete all fields or we will not be able to process your request.
  • Please note that we do not supply powered chairs. For assistance with powered chairs.
  • IF YOU DO NOT ENTER THE PATIENT'S NAME AND AN EMAIL ADDRESS, THE FORM WILL NOT WORK

Patient Information

Name of Person in need: (required)


Contact Email Address: (required)


Address 1:


Address 2:


City:


State:(required)


Zip:


Shipping address if different:


Address 2:


Phone:
  Ext:  


Patient Email Address:


Has Insurance been applied for and denied:


Current Housing Arrangement:


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:


If yes, describe make and model:


Wheelchair Size:


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?:

If yes,the following information is required:


Name of the Health Care Professional or Agency:


Type of Agency:


Complete Address:


Other Comments:



You may contact us by email
or by mail at Chariots of Hope,
Main Office, 45 Barber Pond Road, Bloomfield, CT 06002,
by phone at (860) 242-4673 or by fax at (860) 760-6227.

Website Design by DSI
Website Design by DSI