411PowerChairs

*I am interested for:
*My First Name:
*My Last Name:
*Address:
*Zip:
*Home Phone:	- -
Alternative Phone (Optional):	- -
*Email Address:
*Insurance Carrier:

Can the patient walk well enough to take care of himself at home without experiencing severe pain, severe lack of breath or danger of falling even with a cane or walker?	Yes No
Can the patient independently use a manual wheelchair well enough to take care of himself at home without excessive pain or lack of breath?	Yes No
Does the patient currently live in a Nursing Home or is under Hospice Care	Yes No

As a contracted Medicare provider and insurance coverage specialist, we will process all paperwork on your behalf, including assistance with obtaining authorization from your physician.

► Free Delivery!
► Free Setup!
► Free Insurance Filing!

** Actual cost depends on insurance provider benefits.