img img
  • Home
  • Pre-Order
  • About Us
  • Blog
  • Contact Us
  • Careers
  • Invest Now
Skip to content

Customer Intake Form

  • Please fill out this form as completely as possible.

  • MM slash DD slash YYYY
  • example@example.com
  • TRANSFER PROCESS INFORMATION

  • *Upper-body mobility, hand dexterity and cognitive acuity are required to operate UpLyft in self-transfer mode.

  • PATIENT HEALTH INFORMATION

  • *Disclaimer: UpLyft should not be operated in self-transfer mode by an individual who is taking any type of prescription medication that may unexpectedly cause severe drowsiness.

  • WHEELCHAIR INFORMATION

  • HOME & BEDROOM INFORMATION

  • How much open space is available on each side of the patient's bed?

  • FINAL ADDITIONAL DETAILS

  • DECLARATION

  • I have completed this questionnaire to the best of my knowledge and commit to advising UpLyft if there are any changes to the above information. I understand that upper-body mobility, hand dexterity, cognitive acuity and alertness are required to operate UpLyft in self-transfer mode. I understand that UpLyft shall not be held responsible for any damages that may occur should a patient decide to operate UpLyft in self-transfer mode without exhibiting the above qualifications.

  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY
  • Hidden
  • For any questions or comments when filling out this form, please contact us at sales@uplyfthealth.com or 1-833-753-0666.

  • This field is for validation purposes and should be left unchanged.
Save and Continue Later

Share this:

  • Twitter
  • Facebook

Like this:

Like Loading...
img

UPLYFT YOUR LIFE™ TODAY!

UpLyft® is the world's first seated self-transfer system between bed and wheelchair for people with limited mobility. In about 2 minutes, a person can self-transfer him/herself with UpLyft from a lying down position in bed into their wheelchair.

PRE-ORDER NOW
  • Home
  • Pre-Order
  • About Us
  • Blog
  • Contact Us
  • Facebook
  • Instagram
  • Twitter
  • LinkedIn

Copyright © 2023 UpLyft, Inc. All Rights Reserved.

Close Menu

Reserve My UpLyft

  • Price:
  • Hidden
  • Hidden
  • Hidden
  • Hidden
    MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

Reserve My UpLyft

  • Price:
  • Hidden
  • Hidden
  • Hidden
  • Hidden
    MM slash DD slash YYYY

Let’s Go!

I Want to Give!

  • UpLyft is committed to making a positive impact for people with limited mobility. All contributions will go directly towards providing an UpLyft to an individual or facility in need. Note: If you would like to make a contribution of $5,000 or more, please contact us.
  • $0.00
  • Hidden
  • Hidden
  • Hidden
  • Hidden
    MM slash DD slash YYYY

I Want to Purchase an UpLyft Now!

  • Please enter your information below and one of our dedicated team members will contact you within 24-48 hours.
  • Hidden

My Facility Needs UpLyfting!

  • Please enter your information below and one of our dedicated team members will contact you within 24-48 hours.
  • Hidden

Please tell us why you're interested in UpLyft

Message to Consumers at Home

UpLyft empowers your freedom of mobility, reducing the need for assistance getting in and out of bed.

In the case of individuals who are quadriplegic or not currently in a state to operate UpLyft themselves, caregivers or loved ones can help you without the risk of injury.

It’s much faster, safer, and more enjoyable than being placed into a sling, on top of a body board, or physically lifted by another person.

Message to Healthcare Facilities

Costs associated with back and neck injuries in the healthcare industry amount to approximately $20 billion annually in the United States. Furthermore, over 52% of U.S. healthcare workers complain of chronic back pain that is caused specifically by the manual and physical lifting of patients during transfer.

Protect your healthcare workers and avoid preventable injuries with UpLyft.

Your patients will benefit from a gentle and safe transfer both into and out of their wheelchair.

%d bloggers like this: