Please check the required fields
Person requesting Repair?
Imput first and last name.
Email of person Requesting repair?
Please provided an Email address for follow up.
Location of Wheelchair in need of repair
Room Number or location. (I.E. Rm-208A or Storage)
Wheelchair ID #
Number not issued to chair yet.
Barcode number is:
Barcode number if assigned. If not state "None".
Issue or problem area
Left side break needs adjustment.
Right side break needs adjustment.
Wheelchair not reclining propoperly.
Right side caster needs repair.
Left side caster needs repair.
Right side main wheel needs repair.
Left side main wheel needs repair.
Back is torn.
Seat is torn.
Left arm rest needs repair.
Right arm rest needs repair.
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