Request for Parts and/ or Service

Please fill out the following information to the best of your knowledge. The more information we receive, the better we can assist you. Providing an email address will also allow us to get you a quick response regarding service or ordering parts. Once the form has been submitted, one of our Customer Service Representatives will contact you within approximately 24 business hours. If you would like to check in with us prior to hearing from one of our reps, please visit us on our website and use our chat option. There is a live rep during business hours and after business hours you can leave a message that will be promptly answered when we reopen for business. Thank you for choosing WSR Solutions- we look forward to assisting you!

Owner Information

First Name *
Last Name *
Email * (Please provide email - this is the
best form of contact for quicker response)
Address *
City *
State *
Zip *
Cell Phone *
Alternate Phone *

Medicare Information

If you would like to check eligibility for repairs thru Medicare the below information is required (power chairs and scooters only)
Medicare Number
Date of Birth

Equipment Information
Manufacturer *
Make and Model *
Serial Number
When was your equipment purchased/ received (month and year)?
Where was your equipment purchased from?

Service and/or Parts needed
(Please provide the below information to expedite service)

We would be happy to locate a technician of ours in your area. Our services are completed at your home and the tech service call fee begins at $185.

Please tell us which of the following applies: Would you like an evaluation, do you want a quote on a part, have parts that need to be installed with you now, or want a quote on a part AND a tech to install?

If you have parts on site for repair, please list what you have on site that needs to be installed:

Do you need a quote on parts? (If you would like a quote on parts serial number is required) List parts here:

Please tell us a little about what your concerns/ issues are with your equipment:


SUBMIT