Client / Chair Information Form
for Wheeleez™ Wheelchair Beach Conversion Kit

In order to help you choose the right conversion kit for your chair, please provide the following. We’ll review it and contact you.

  • Client Information:

  • Chair Rider Information:

  • Wheelchair Information:

  • Pictures Required:
  • Accepted file types: jpg, jpeg, png, gif.
  • Accepted file types: jpg, jpeg, png, gif.
  • Accepted file types: jpg, jpeg, png, gif.