Power Chairs and Scooters at Little or No Cost - Toll Free 1.866.387.2668 // 24 Hours Daily
Physician Center

Patient Referral Form

Power Chairs and Scooters typically have profound effects on a patient’s life.  When you have patients that are having difficulty walking and are at risk of falling, u-Scoot would like to partner with you to help improve their quality of life. Submit the information requested below and a dedicated Case Manager will follow up with both your patient and your office to help get them approved for Power Chair or Scooter.

Physician Information (All fields but Email Address are required.)

Doctor Name

*

Office Contact

*

Phone

*

Fax

*

Email Address

Patient Information (All fields but Email Address are required.)

Patient Name

*

Primary Insurance

*

Secondary Insurance

*

Medicare #

*

Gender

*

City

*

State

*

Zip

*

Phone

*

Date of Birth

*

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