Box Wheelchairs Online Wheelchair Order Form Box Wheelchair Online Order Form Download a pdf version and email pdf to Mike instead. Name Name First First Last Last Phone Email Delivery Options Pick up at shop Ship to Customer My Shipping Address is different than my Billing Address. No Yes I have an international billing address. No Yes Billing Address Billing Address Billing Address Billing Address City City State State Zip Code Zip Code International Billing Address International Billing Address International Billing Address International Billing Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country I have an international shipping address. Shipping Address Shipping Address Shipping Address Shipping Address City City State State Zip Code Zip Code International Shipping Address International Shipping Address International Shipping Address International Shipping Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Wheelchair Frames Daily Chair Rigid Frame Daily Chair Suspension Frame Dancing Chair with 1 Sport Anti-tip Bar WCMX (skate daily, or off road) Land Shark (ATC Chair) Tennis Frame Basketball Frame Beach Bomber Frame Center of Gravity Adjustable Fixed Frame Add-On Options Grind Bar (*** WCMX only ***) Taper after Seat Depth One-Arm Drive Do you use a power assist on your wheelchair? No Yes Type of Power Assist ZX1 Power Add On Free Wheel Smart Drive Set-up Power Assist for Only Type Chosen Above. No Yes Frame Color Finish Gloss Matte Raw Polish Frame Color Black Green Pink Fire Engine Red Silver Raspberry Neon Orange Blue Sparkle Sky Blue Light Gray White Orange Reed Green Neon Green Powder Blue Red Cobalt Blue Dark Gray Purple Yellow Sparkle Green Gun Smoke Silver Teal Custom Color Custom Color Select custom color from https://www.prismaticpowders.com *** Prices may vary with Custom Colors *** Suspension Chair (Axle & Footrest Color) Enter name of color here from “Frame Color” selections above or a custom color can be chosen from https://www.prismaticpowders.com *** Prices may vary with Custom Colors *** Daily-Use Wheelchair Optional Accessories Single Removable Anti-tip Bar Dual Removable Anti-tip Bars Bolt-on Push Handles Integrated Push Handles Calf Strap BP Seat Belt BP Push Lox Wheel Locks Sport Wheelchair Optional Accessories Built-in Single Anti-tip Bar Built-in Dual Anti-tip Bar Hip Ratchet Straps Feet Ratchet Straps Knee Ratchet Straps Shocks Fox Shock WCMX Coil Shocks Brake Options Out-Front Scissor Locks Push Locks Foot Plate Options Black Plastic Diamond Plate (WCMX chair) Flared Sides None Backrest Upholstery Adjustable Tension Backrest ADI 10″ ADI 13″ ADI 16″ ADI Custom Height ADI Contour Cushion Standard 2″ Foam Supracor Roho Cushion Notes Rear Wheel Size 20″ 22″ 24″ 25″ 26″ Sand Rear Wheel – Hub Color & Axle Size 1/2″ axle – Silver hub 1/2″ axle – Black hub 5/8″ axle – Red hub 5/8″ axle – Black hub Please ask about other Hub and Rim colors. *** Prices may vary with custom colors *** Rear Wheel Spokes 12-Spoke 24-Spoke Rear Wheel Spoke Color Black Blue Green Pink Orange Red Yellow White Purple Rear Wheel Tires Schwalbe Rightrun Schwalbe Marathon Solid Knobby Sand Hand Rims Silver Anodized Black Anodized TC Vinyl Coated Q Grip Natural Fit Hand Rim Mount Short Tab Long Tab TC Type Stainless Max What kind of Q Grip? Front Forks Recoil Suspension Fork Recoil Suspension Wide MB 3″ MB 4″ MB 5″ 10″ Forks for Beach Bomber MB Wide Front Caster Wheels 3″ x 1″ (Sports) 3 x 1.4 4 x 1.4 5 x 1.4 Skate Caster 10″ Sand /Off Road Wide 100mm Caster Hub Color Standard Black Custom Color We can order special colors. *** Prices may vary *** Accessory Add-Ons Fox Shock Pump Cup holder Additional Wheelchair Personal Requirement Notes Add any additional special requirements for your build here. A) Front Seat Height B) Rear Seat Height C) Backrest Height D) Seat Depth E) Extra for Hand Grip F) Seat to Footrest G) Diagonal Dimension H) Center of Gravity I) Seat Width J) Inside Wheel Clearance K) Inside Foot Width L) Camber M) Backrest Angle N) Side Guards Welded O) Folding Back Not with ADI backrest Captcha Submit Order If you are human, leave this field blank.
