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intake

Your Custom
Wheelchair Consultation

Custom Wheelchair Intake Form
Intake

WHO IS THE CHAIR FOR?

Myself
  • Myself
  • A family member
  • A client/patient
  • Other

CURRENT MOBILITY SETUP

Yes – daily use
  • Yes – daily use
  • Yes – part-time use
  • No – first wheelchair
  • Not sure yet

DAILY USE & LIFESTYLE

Less than 4 hours
  • Less than 4 hours
  • 4–8 hours
  • 8+ hours

CUSTOMIZATION GOALS

FUNDING & PAYMENT PATHWAY

Private pay
  • Private pay
  • Insurance (Medicaid / Medicare / Private Insurance)
  • Grant or nonprofit assistance
  • Not sure yet
Yes
  • Yes
  • No

TIMELINE & URGENCY

ASAP
  • ASAP
  • Within 30–60 days
  • Within 3–6 months
  • Just researching

ADDITIONAL INFORMATION

CONSENT & NEXT STEPS

Confirmation: By submitting this form, you understand that custom wheelchairs require consultation and final specifications are determined after assessment.Thank you for starting your custom wheelchair consultation with TNT 360 Mobility. A mobility specialist will review your information and contact you within 24–48 hours to discuss fit, funding, and next steps.
 
r e c o i l s
Advance Technology

Push its limits

Specifically designed for users who push their wheelchairs to the max, the Recoil is avaible in several different spring weights, so that you can custom tailor the ride to your specific wants and needs!

Suspension Forks
Play
Filling out

Measurements

B O X

TNT 360 Mobility

If you are looking for the smoothest way to reach the top speed & cruise in front of your competitors, you’re in the right place. Welcome to TNT 360 Mobility

QUICK INFO

Monday-Friday: 9am to 5pm; Satuday: 10am to 2pm
New Orleans, LA
1 (504) 882-0855
info@tnt360mobility.com tnt60mobility@gmail.com