Efoldi Assessment & Warranty Form printable pdf download

eFOLDi Assessment & Warranty Form

User Name

Model

Serial No.

User

Address

Purchase Date

Dealer

User

Disability

Details

Any information disclosed is protected under the Data Protection Act 1998 and will not be disclosed to any third parties

Progressive ⃝ Yes

Eyesight ⃝ Good

Illness ⃝ No

⃝ Acceptable (Can read a number plated at 12.3 meters)

Main Use ⃝ Indoors

Hearing ⃝ Good

⃝ Outdoors (Pedestrian areas)* Ability ⃝ Acceptable (Can hear the audible warnings on the product)

*Class 3/C Scooters can be used on public roads

…………………………………………………………………………………………………………………………………………………………………………………………………………

Fold along dotted line

Balance – Standing ⃝ Good

⃝ Acceptable (Person can balance without the aid of support)

Balance – Seated ⃝ Good

⃝ Acceptable (Persons must use the lapbelt if fitted and the armrests in the down position)

Concentration

⃝ Good

⃝ Poor (Attendant to be person when the product is being used)

Co‐ordination

⃝ Good

⃝ Acceptable (Person can operate all functions safely and accurately on the product)

eFOLDi suggests that your ability to safely use the product should be assesses on a regular basis.

User Wight (kg)

User Height (m)

I, (the Dealer) confirm that the product has been demonstrated prior to

Signed

commissioning / delivery and is suitable for use by the person named above

Signed

I, (the User) confirm the above is true and correct and that the

product has been demonstrated and I am aware of it’s functions. I

agree to read the manual prior to using the product (Please tick box)

This form must be filled, signed and returned to eFOLDi or our dealer to validate your warranty. Please see Warranty terms and

conditions.

Efoldi Assessment & Warranty Form