Quote Request
  1. The Merlexi Craft Series of Wheelchairs: Liberty I, Liberty II and MRI Wheelchair are customized to meet the needs of our customers. Because of this customization, we ask that you complete the quote request form below. If you prefer to speak with us directly, please call us at 1-800-959-4765.
  2. Your Name(*)
    Please let us know your name.
  3. Company
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  4. Your Phone
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  5. Your Email(*)
    Please let us know your email address.
  6. Which wheelchair are you interested in purchasing?(*)
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  7. ________________________________
  8. Enter information for the wheelchair user below.
  9. Gender(*)
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  10. Which describes the user?(*)
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  11. Primary use of chair(*)
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  12. Seat Angle Preference
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  13. Chair Color
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  14. Upon receipt of this form, we will contact you for more detailed information including but not limited to the need for additional inflatable backs and cover and whether you would like standard bolt footrests or Quick Release footrests.
  15. Any Additional Comments(*)
    Please let us know your message.