Institutional Wheelchair Request Form

For hospitals, clinics, rehabilitation centers and NGOs requesting wheelchairs on behalf of their patients.

Organization Information

Institution Name *

Organization Number *

Institution Type *

If Other, please specify

Official Address *

Website / Email *

Contact Person *

Title *

Phone Number *

Patient Demographics & Need

Total Number of Wheelchairs Requested *

Primary Patient Demographic Served *

What is the primary cause of need among your patients? * e.g. poverty, disability, post-surgery recovery, lack of local supply

Institutional Capacity & Justification

Average Number of Patients Treated Monthly *

How will these wheelchairs benefit your institution and patients? *

Do you have staff trained to assist patients with mobility devices? *

Where will the wheelchairs be stored when not in use? *

Delivery & Acceptance Terms

Delivery Address *

Authorized Signatory Name *

Title *

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