Expression of interest only hire form

We are delighted you wish to hire the X8 Wheelchair! In order to proceed with your booking, please fill out and submit the form below.

Complete the form we need in order to proceed with your booking. You will need to upload your SMA diagnosis letter, proof of address and one form of ID (either a passport of driving licence)

Please ensure you have read the FAQ’s sheet prior to booking the chair as this will answer any questions you might have.

By hiring the X8 Wheelchair you agree to the Terms and Conditions

If you still have further queries please contact X8@smauk.org.uk

X8 Off Road Wheelchair Hire Form

A. About the applicant

Name(Required)

First

Last

Date of birth(Required)

Parent/Guardian (if under18) Please note users must be aged 14 or over to use the chair

First

Last

Email(Required)

Enter Email

Confirm Email

Home Address(Required)

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

Address for delivery of the X8 (if different from your home address)

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

Address for collection of the X8 (if different from your home address)

Street Address

Address Line 2

City

County / State / Region

ZIP / Postal Code

Country

Phone(Required)

Please tell us why you are requesting hire of the X8 wheelchair(Required)

I consent to any photos that I send in to be used for future promotion for the X8 hire by SMA UK(Required)

Yes

F. Application documents

SMA diagnoisis letter(Required)

Max. file size: 128 MB.

Proof of registered address (utility bill dated the last three months)(Required)

Max. file size: 128 MB.

Proof of ID (passport or driving licence)(Required)

Max. file size: 128 MB.

You must agree and adhere to the Terms and Conditions that come with the hire of the X8 Wheelchair(Required)

I agree to the terms and conditions

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