Order Request Form


Most of our cushions are built to order, so please fill out the form below, and a representative will be in contact shortly to gather additional information and initiate your order.


Having relevant information available when our specialists contact you — such as the cushion style you currently use, cushion/wheelchair seat pan size, your current height and weight, and relevant medical conditions — is extremely helpful. This information assists us in personalizing your cushion and making certain is perfect for you.


Please fill this form to the best of your knowledge so we may better assist you. This is not an official order form, only an initial request, please do NOT include any credit card information in this form.


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2016 EASE Seating Systems   866-376-1878

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