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Wheelchair Assessment Pricing Form

Is the health condition progressive and/or does symptom severity fluctuate?
Yes
No
Any cognitive or visual impairments?
Yes
No
Currently walking independently (with or without aids, for example cane or walker), even for short distances only? If assistance for walking is required, please select “no”.
Yes
No
Is the wheelchair needed for interim use/community use only? For example, going out to restaurant with family or medical appointments etc.
Yes
No
Currently using a wheelchair as primary method of mobility?
Yes
No
If yes, select all that apply:
Please select a level of documentation you would like to receive with this service (select one)
None
Brief Letter/Email
Comprehensive Report

Thank you! Once we have received your pricing form, you will receive a call within 2 business days. You will then be provided with pricing and intake information. If you are interested in proceeding, our OTs typically can book an assessment within 2 weeks of receiving the completed intake forms.  

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