Order Form

This order form is for ordering Manual Wheelchairs, Walkers, Ramps and Lift Chairs. If you would like to order an electric wheelchair or scooter,  please contact us by phone, fax or email. To place an order for walkers or rollators, please use our WALKER ORDER form.

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  Please be sure to enter a shipping address if your mailing address is a P.O. Box and complete the form entirely before submitting. We do have a 30 day return policy. If you are unhappy with the item you have purchased, for any reason, you may return it within 30 days for a refund of the purchase price, less a 20% restocking fee. For details, please see our RETURN POLICY.

Please enter your name

First name:    Last name:   

Please give us your mailing address:

Address 1:   



State:      ZIP/Postal code:

If your shipping address is different from your mailing address, please list it below:

Shipping First Name:

Shipping Last Name:

Address 1:   



State:      ZIP/Postal code:

E-mail address:   

Phone number:      NOTE: Contact Telephone Number is Required

Optional Information

Fax number:   

Please select the items you would like to order:

Please enter the Item number's of the Ramp(s) you would like to order:

Most of our ramp prices include shipping within the continental U.S. However, some of the ramps are to large to be shipped via U.P.S. and shipping charges will be added to the price, where you see a " +ship" next to the price. We will contact you with the total price of the ramp you order, including shipping charges, before your order is processed.

Item 1 #:    Quantity    Item # 4 Quantity

Item 2 #:    Quantity    Item # 5 Quantity

Item 3 #:    Quantity    Item # 6 Quantity 

Please select the Lift Chair you would like to order:

Casual Line

Model #     Color

Gentle Line

Model #     Color

Luxury Line

Model #     Color 


Please select the manual wheelchair you would like to order:

Select the credit card you would like to use:

       Master Card



       American Express

Please enter your credit card number

Please enter the 3 or 4 digit security code on your credit card:

Please enter the expiration date on the credit card.

Additional questions, comments:

By clicking the "Submit" button below, you agree that you have read and accept our return policy.

Thank You!