DB1 MANUAL WHEELCHAIR SERVICE RECORD
Service Ref No.
User / Client Name ..............................................................................................................................
Address.................................................................................................................................................
................................................................................................................................................................
MODEL DESCRIPTION and SIZE .............................................................................................................
OTHER FEATURES......................................................................................................................................
To ensure that your wheelchair remains in first class working order
Please ensure that the following checks are carried out at recommended
service intervals by an approved distributor/service agent.
TICK BOX when check is completed
SERVICE No 1 2 3 4 5 6 7 8 9 10
WHEELS
HANDRIMS
TYRES
BRAKES
CASTORS
FOOTRESTS
ARMRESTS
MOVING PARTS
MANOEUVRABILITY
FRAME
ANTI TIPPERS
HAND GRIPS
UPHOLSTERY
LABELLING
ACCESSORY
OTHER
CHECKERS INITIALS
DATE
Greencare Mobility For safety, users should be aware of routine maintenance responsibilities
Riverside Park Road Technical check reference information for service engineers is on gcqa 007
Middlesbrough TS2 1UU
tel 01642 353492
fax 01642 223313
e mail info@greencaremobility.com for ………………………………..…....…Wheelchair Service
When all tick boxes arecompleted issue a second form as sheet 2 if required.
It is essential for specification of any spare parts.
This form to be included, and retained, with service information.
RECOMMENDED SERVICE INTERVAL assessed according to gcqa 017
Form checked and issued by ………………………………..
To be completed at time of issue by wheelchair service centre
Service Issue DateGreencare BTO Serial Number
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