VMS - Virtual Mounting Solutions

VMS Application Form

Request your individual solution right here, it takes just a few quick steps!

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Your Contact Information


Organization

Name

Rehadapt Reseller

Optional Please specify the REHAdapt reseller you want to handle your request (needed if there is more than one reseller in your country):

Requestor

Name

Street

City/State

ZIP Code

Client

Name

Street

City/State

ZIP Code

Your Wheelchair


Manufacturer

Name

Is a device adapter plate needed (comes sometimes included with the device)?
yesno

Model

Name

Mount side:
rightleftno preference

Device

Name

Quickshift-Handles for the joints desired (allows for tool-less repositioning, but might provoke unnecessary tampering)?
yesno

Slip-Out-Safeguards desired (hinder tubes from slipping out of joints during repositioning, but makes exchanging tubes difficult)?
yesno

Any special requirements?

Your Pictures


VERY IMPORTANT

Take pictures of the wheelchair in the listed viewing angles.
Make sure to include device or facsimile at the desired position!


Front

Angular

Side


Under Seat

Detail

Behind


Contact Email (required)

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Your Name (required)

Your Email (required)

Your Telephone Number