Tongue Switch

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Optional End User Profile

Help us help you! The following optional questions help us to understand the assistive technology end-user's needs and goals. We use this information ONLY to make more appropriate recommendations and provide more personalized customer service when talking to you.

Account Type
Assistive Technology End User Assistive Technology Professional - make referrals Assistive Technology Vendor / Installer Client of Reseller DME - Durable Medical Equipment Dealer Family / Friend Helping User Gov - Veterans Administration Gov - Vocational Rehabilitation Hospital / Rehabilitation Center Insurance Provider - Medical Insurance Provider - Workers Comp Nonprofit Organization Orthotist / Prosthetist School - K-12 School - University/College Travel Service

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by Ability or Control Method: Ctrl-Click all that apply
Arm Movement, Limited Finger Dexterity Some Finger Dexterity, No Arm Movement Clear English Speaking Voice Slurred Speech or Heavy Accent Breath- Blow or Suck Lightly Mouth, Tongue, or Facial Gestures Good Head Movement Move Feet or Toes

by Disability or Limitation - Ctrl-click all that apply
No Head Movement - Tongue/Lips/Facial Gestures Only Head Movement Only No Arm Movement with some Finger Dexterity Arm Movement with Limited Finger Dexterity C1-C3 Quadriplegia C4 Quadriplegia C5 Quadriplegia C6-C7 Quadriplegia ALS - Lou Gehrig's Disease Cerebral Palsy Muscular Dystrophy or SMA Multiple Sclerosis Paraplegia Limited Speech or Nonvocal Stroke Unable to Walk - Wheelchair User Brachial Plexus Injury Limited Hearing or Deaf Limited Vision or Blind Arthritis, RSI, Tendinitis Elderly Not Disabled, Temporarily Able-Bodied

End User's Date of Birth

Gender
Male Female

Tax/VAT ID for Nonprofit/Reseller/Gov Exemption

Wheelchair Manufacturer
21st Century - Bounder Colours Drive Medical Hoveround Invacare Levo Other Permobil Pride Redman Sunrise/Quickie TiLite

Wheelchair Model

Additional Details/Notes

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