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What type of chair do you own?
Are you in a wheelchair?
Yes
Manual
No
Power
Sometimes
None
How many hour a day are you in your chair?
How often does your chair need repairing?
Less than 4
6 months or less
Between 4-8 hours
6 months to a year
Over 8 hours
Every 1 to 2 years
Tell me what I can do to make my customers
Address:
City:
State/Prov:
Country:
Zip/Post. code:
Phone:
E-mail: