Customer Form2019-01-04T20:48:41+00:00

Customer Information Form

  • Your Name*


    Your Email*


    Delivery Address*


    Pin Code*


    Contact Number*


    Body Weight*


    Bathroom Door Width (Inches)*


    Obstacle Height Between Bathroom Floor and Adjacent Room (mm)*


    Commode Height (mm)*


    Bed Height Including Mattress (mm)


    Special Comments/Requirements If Any


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