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Issue_A June 2012 17 Dash X
MANUAL WHEELCHAIR SERVICE
RECORD
–
COMPLETED BY DEALER
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.
Users should be made aware of service requirements : Non completion of this form may affect warranty
Client Name ..........................................................................................................................................
Address.................................................................................................................................................
................................................................................................................................................................
Batch Code
Wheelchair Serial Number
Service Issue
Date
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.
SERVICE
NUMBER
TICK BOX IF CHECKED AND OK
PLACE "R" IN BOX IF REPLACED
CHECKLIST
1
2
3
4
5
6
7
8
9
10
WHEELS
TYRES
CASTORS
BRAKES
FOOTRESTS
FRAME
ARMRESTS
PUSH HANDLES
HANDGRIPS
PAINTWORK
MANUAL WHEELCHAIR
SERVICE RECORD
Service Ref No.
