Request Funding Help

Personal Information

First Name:

Last Name:

Email:

Phone:

Zip Code:

Assistance Details

Do you have difficulty getting in and out of the shower or bath?

Which product do you need funding assistance with?

Do you have a qualifying medical diagnosis?

ALS

Spinal Cord Injury

Multiple Sclerosis

Spina Bifida

Aging-in-place (Elderly with loss of mobility)

Other

Tell us about your current challenges:

800 characters max

Do you currently have Insurance?

By submitting this form, you give SolutionBased Inc. permission to share your request details with third-party companies to assist you. Please note, we cannot guarantee your request will be fulfilled.