Specialized Seating Application

Email(Required)

Phone

Client's Last Name(Required)

Please attach completed application:(Required)

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Accepted file types: jpg, gif, png, webp, pdf, Max. file size: 100 MB, Max. files: 1.

Additional supporting documentation:

(photographs, palliative care documentation, justification letters, etc)

Drop files here or

Accepted file types: jpg, gif, png, webp, pdf, Max. file size: 100 MB, Max. files: 10.

Specialized Seating Application – Online