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ENTER TO WIN A SET OF MAGICWHEELS™ :: ENTRY FORM
Required *

Name: * Address: *
Phone: * City: *
E-Mail: * State:  *
VA Hospital/Clinic: * Zip: *
The name of your physical therapist /phone number (to confirm MagicWheels would work for you) *
Type of manual WC / Wheel Size / Year / Model # *
How did you hear about MagicWheels? *
Would you like to schedule a test drive? * No
Please tell us about your level of injury or other reason for using a manual wheelchair and how
you think MagicWheels will help you (250 words or less). This will let us verify our wheels will suit your needs.
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