I AM*

BEST TIME TO CONTACT YOU* Please tell us the most convenient time to reach you by phone.

FUNDING SOURCES

I’ll be purchasing directly from you. I’ll be using MobilityFunder® (Crowdfunding/Group-Gifting) I will be purchasing first, then filing a claim with my insurance I will be using a Trust, Waiver, or Charity Funding Source Purchase Order Other

Give us an idea of your funding sources. Please check all of those that you plan on using for this piece of equipment. More than one answer is OK.

Give us some information about the equipment you are interested in, users’s diagnosis, age, height, weight, etc. What has worked in the past and what hasn't.

Picture Upload:

Photos can be very helpful if you need significant guidance in the equipment purchasing process. Please send us a photo or two

+ ADD ANOTHER PHOTO