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Users should be made aware of service requirements : Non completion of this form may affect warranty
Client Name ..........................................................................................................................................
Address.................................................................................................................................................
................................................................................................................................................................
Batch Code
TYPE/MODEL.............................................................................................................................................
OTHER FEATURES..................................................................................................................................
RECOMMENDED SERVICE INTERVAL.............MONTHS : SIGNED .............................
To ensure that your wheelchair remains in first class working order please ensure that the following
checks are carried out at recommended service intervals by an approved distributor/service agent.
CHECKLIST
WHEELS
TYRES
HANDRIMS
CASTORS
BRAKES
FOOTRESTS
FRAME
ARMRESTS
PUSH HANDLES
HANDGRIPS
PAINTWORK
CUSHION
UPHOLSTERY
ATTACHMENTS
TIE DOWN POINTS
OCCUPANT BELT
GENERAL CONDITION
CHECKERS INITIALS
DATE
REMPLOY HEALTHCARE (MOBILITY)
R Healthcare Technical Information Manual - Dash
MANUAL WHEELCHAIR SERVICE RECORD
Service Ref No.
This form to be completed at time of issue by approved distributor.
It is essential for specification of any spare parts.
This form to be included, and retained, with user guide information.
Wheelchair Serial Number
SERVICE NUMBER
1
2
3
00 08 71 00. Aug 2003. Rev E
Page 30
Service Issue Date
TICK BOX IF CHECKED AND OK
PLACE "R" IN BOX IF REPLACED
4
5
6
7
8
9
10
March 2007 Revision B
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