Ability KC Wheelchair Wash

Wheelchair Wash

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please select your chair type:

Manual

Power

Scooter

Please select one of the following:

I will remain in my chair during the wash.

I will transfer out of my chair into an Ability KC chair.

I would like to transfer into another chair with help from an Ability KC therapist.

Estimated Time of Arrival

Comments

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