Chair-A-Medics Service Request Form
Questions? Please email us at
or give us a call at (919) 228-4478.
What is your facility name?
What is your facility location?
Who should we contact about this repair?
What is the contact person's email address?
What is the priority of your request?
We don't have enough chairs for our shifts.
Our situation is not dire, but come as soon as you can.
We have extra chairs, so there is no rush.
Page 1 of 11
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service