Chair Request Questionnaire

Child's Name

Parent's Name

Email

Phone Number

Child's Weight (lbs.)

Child's Height(inches)

Child's Age

Address

City

State

Zip Code

Country

Medical Diagnosis Related to Mobility Challenges:

Does your child currently receive physical therapy for mobility related issues?
Is your child able to sit unassisted?
Does your child have the ability to crawl?
Does your child currently use any other devices to assist with mobility?

Medical Devices Used
(i.e. Oxygen, Feeding, etc.)

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