Standing Wheelchair

LEVO Standing Wheelchair Technology – Mobility that redefines your life
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Levo USA
7105 Northland Terrace
Brooklyn Park, MN 55428
Driving Directions

teamlevousa@danetechnologies.com		 1-888-LEVOUSA  (1-888-538-6872) 
763-544-7779
763-544-4234 fax
 
 

Thank you for your interest in our Mobility/Ability Solutions! If you would like us to contact you with more
information please submit your email address here:

Email

The following information is not necessary for us to contact you, but it will provide extremely helpful
details that assist us in giving the most accurate recommendation. Please complete the questionnaire below.

Contact Information   Relation to Client
Name Myself
Address Relative
City Friend
State  
Zip Code  
Phone  

Reason for Standing Assistance / Diagnosis

Spinal Cord Injury  Muscular Dystrophy
Multiple Sclerosis Stroke
Cerebral Palsy  Other

Height  
Weight  

How / Why Use (Check All Applicable)

Home Inside
Work Outside
School Primary Chair
Standing Exercise Secondary Chair
Medical Benefits In Vehicle/Transport Van

Sources of Funding

Workers Compensation Vocation Rehabilitation
Veteran’s Affairs Charitable Support
Auto Accident Insurance Medical Assistance / Medicaid
Private Insurance Family / Individual

Are you working with a Dealer / DME / Medical Professional?

Yes No

Contact  
Company Name  
Address  
Phone  
Email  

Comments/Questions

Please include any additional comments or questions you have

 
 
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