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Are these modifications for your home or someone else’s?
Are these modifications for your home or someone else’s?
My Home
My Parent or Grandparent
My Patient or Client
Someone Else
Select the type of residence.
Select the type of residence.
Single-Family Home
Condo
Mobile Home
Other
How can we help modify this home for accessibility?
How can we help modify this home for accessibility?(Stairway, Tub/Shower, Entryway)
Stairway(s)
Tub or Shower
Entryway
How many staircases do you need modified?
Number of Indoor Staircases
Number of Outdoor Staircases
Provide the estimated weight of the primary user.
Provide the estimated weight of the primary user.
100-200 pounds
201-300 pounds
301-400 pounds
401-500 pounds
What do you need modified?
What do you need modified?(Tub, Shower, Both)
Tub
Shower
Both
Are you having trouble stepping over your tub?
Are you having trouble stepping over your tub?
Yes
No
What kind of tub do you have?
What kind of tub do you have?
Fiberglass
Cast Iron
Other/I Don’t Know
Would you like grab bars?
Would you like grab bars?
Yes
No
I'm Not Sure
Would you like a seat?
Would you like a seat?
No
Yes
I'm Not Sure
What do you need modified?
What do you need modified?(Tub & Shower, Shower Only)
Tub & Shower
Shower Only
Would you like grab bars?
Would you like grab bars?
Yes
No
I'm Not Sure
Would you like a seat?
Would you like a seat?
Yes
No
I'm Not Sure
Would you like a detachable/handheld showerhead?
Would you like a detachable/handheld showerhead?
Yes
No
I'm Not Sure
Would you like your shower remodel to have doors?
Would you like your shower remodel to have doors?
Yes
No
I'm Not Sure
Where is the home’s primary point of entry?
Where is the home’s primary point of entry?
Front Door
Back Door
Garage
Porch
How can we help modify this home for accessibility?
How can we help modify this home for accessibility(Stairlift, Ramp Platform Lift)?
Stairlift
Ramp
Platform Lift
How many stairs do you have in this entry that we should adjust for?
How many stairs do you have in this entry that we should adjust for?
Just a Lip
1-3
4-6
7-10+
I'm Not Sure
How soon do you need your modifications made?
How soon do you need your modifications made?
As Soon As Possible
Within 2 Weeks
Within 4 Weeks
Within 6 Weeks
No Rush
Let us know how to get in touch with you.
Name
*
Phone
*
Email
*
Zip Code
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Phone
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