Application to Receive a Lift ChairSee the map below for our delivery area. Lift Chair Recipient's Name * First Name Last Name Date of BIrth Date of Diagnosis * Lift Chair Recipient's Email * Does the Lift Chair Recipient have difficulty speaking on the phone?? * Yes No Weight * Height * Leg Measurement See Below for Visual * Measure from the bottom of the foot to the back of the knee. Address of Delivery * Address 1 Address 2 City State/Province Zip/Postal Code Country Caregiver's Name Caregiver's Phone (###) ### #### Caregiver's Email Who referred you for a lift chair? * Thank you!
