Product Issue
Product Name
Enter the product name here
Your answer
Fitting Date
When were you fitted for this chair?
Your answer
Serial Number
If you know the serial number please type it here
Your answer
Date problem occured
When did this problem start?
Your answer
Location of problem
What on your chair is giving you issues?
Type of problem
Severity of problem
Observed or reported reason for problem
Description of problem
Please briefly describe the issues you are having with this chair
Your answer
Has the user performed regular maintenance?
Do you think the problem occurred during normal and acceptable use of the wheelchair?
If 'No', what activity caused the problem in your opinion?
Your answer
Please briefly describe who you are
Are you the user of this chair, a clinician, a family member filling out the form for someone else? Let us know here.
Your answer
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