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GALA Y LITE account InformationOrder Date:Account #: Business Name: Ship to Address: Fax: P.O.#: Phone: City: State:Contact: Zip Code:Item FUTURE OBILITYParts #ECodeRetail Price1. FRAME TYPE A103K$00052,195.00Wet
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This form is used for ordering lightweight manual wheelchairs from the Galaxy Lite series.
Healthcare providers and medical institutions are required to file this form when ordering lightweight manual wheelchairs.
To fill out the form, you need to provide patient information, healthcare provider details, wheelchair specifications, and any additional notes or special requirements.
The purpose of this form is to facilitate the ordering process for lightweight manual wheelchairs from the Galaxy Lite series.
The form must include patient's name, contact information, healthcare provider's details, wheelchair specifications, and any special requirements or notes.
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