Text Box: Les Brazier Special Vehicles Text Box: Personal Profile Text Box: There are many variables associated with meeting wheelchair transport needs. The information collected on the  form will assist us in evaluating your needs and providing you with meaningful information. We assure you all information provided will be treated in the strictest confidence. We We Text Box: Profile of Wheelchair User Text Box: The following questions will give us the needed information to help us in providing you with correct information about a vehicle which will suit your needs. Text Box:  Vehicle is required for?   Text Box: Make of Wheelchair (if electric) & drive, front or rear? Text Box: Maximum overall height ‘H’ (see Figure 1) Text Box: Overall length ‘L’ (see Figure 1) Text Box: Comments: Text Box: Name & Address: Text Box: Phone: Text Box: E-mail: Required Field: Text Box: Width to outside of wider wheels (select the wider wheels) Text Box: Width at widest point of chair Text Box: Measure to the higher point - Top of head or headrest     Text Box: Allow for foot overhang and motors, bars etc at rear     Text Box: Weight - Please provide the approximate overall weight, electric wheelchair and passenger Text Box: Is your wheelchair is specially modified? If so please give specific details in the comment section below. Text Box: Allow for foot overhang and motors, bars etc at rear     Text Box: Make Text Box: mm Text Box: mm Text Box: kg Text Box: mm Text Box: mm Text Box:  
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