Order Form Customer Information Type of Disability Paraplegic Quadriplegic Multiple Sclerosis Other If other please explain below Physical Problems Lean to the left or right ? Boney Butt? Yes No Sit with knees together? Yes No Hip Bones Modified? Yes No Men use Catheter or Urnial ? Ishial Modified? Yes No Feeling of Pain? Yes No Amputation? Left Right Both Sores Healing or Open ? Level of Amputation Location of sore(s)? Items of Interest Cushions Mattresses G5 G100 TheraFlo 2000 Airodyne 1400/1450 Premier Stage1 Stage 1 Waterproof Airodyne 1100 Effect 5000 Contact Information Billing Info Shipping Info (If different then Billing) *Name: Name: *Address: Address: *City: City: *State: State: *Zip: Zip: *Phone: (999)999-9999 Phone: (999)999-9999 *Email: Email: Fields with * are required to Submit form

We will contact you to get your credit card information. We accept    Visa         MasterCard        Discover American Express

About us and how we do business... We are a small business and usually deal directly with our customers. Over the years, we have helped many people to be up in their chairs more hours a day, yet pressure sore free! Perhaps even more important, is a customer that has a problem with anything we build or sell; we can be reached on our toll free number - 1-866-376-1878 between 8:00 am and 4:00 pm (P.S.T), Monday through Friday. We know our products better than anyone else, after all, we designed and built them! If you need after-sale service, please call and you will be connected with a skilled technician who can quickly identify what is wrong by asking a few questions. Then, if the unit has had a malfunction, we can ship a replacement unit overnight anywhere in the U.S. You can them return the malfunctioning unit to us. We design and build the very best Alternating Pressure Cushion Systems in the world and back them up with the quickest and best "after sale service".

EASE Seating 8716 Skyway, Paradise, CA 95969
1-866-376-1878 TOLL FREE
Email us at: comfort@easecushion.com