Wheelchair Assessment Form :: Jubilee Automotive Group Ltd

Please complete and submit the simple form below to tell us about the wheelchair and occupant.

Today's date

Your full name

(please confirm your full name) e.g. Mr Robert Jones

Your phone number

(please confirm your best contact phone number)

Your email address

About the wheelchair & occupant

Wheelchair + occupant overall length (in millimetres mm)

(please confirm the overall length from the rearmost point of the wheelchair to the tip of the toes of the wheelchair occupant) typically 800 to 1400 (numbers only please)

Wheelchair + occupant, seated height (in millimetres mm)

(please enter the relaxed seated height of the wheelchair occupant) typically 900 to 1600 (numbers only please)

Wheelchair low level overall width (in millimetres mm)

(please enter the overall low level width of the wheelchair) typically 500 to 800

Clearance height of the foot pedestals (in millimetres mm)

(please confirm the maximum ground clearance of the foot pedestals) typically 60 to 300 (numbers only please)

Comments

(please let us know any other relevant information)