Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Address*

Was your wheelchair damaged by an airline?*

Yes

Which airline(s) were you flying when the damage occurred?*

Which airport were you at when the damage occurred? (If unsure then please list all airports visited during your travel.)*

What date was your wheelchair damaged?*

Did you submit a formal repair request to the airline to fix any damage?*

Yes

Did the airline agree to fix the damage?*

Yes

About how long did it take to get your wheelchair fully fixed or replaced?*

What type of wheelchair was it?*

What was the make and model of your wheelchair?*

Describe the damage to your wheelchair*

Do you have images of the damaged chair?*

Yes

When would be a good time to call you?

Central Time

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I Consent