Technician Support Form

Dealer/Provider*

Dealer First Name*

Dealer Last Name*

Dealer Contact Number

State (Australia)

Dealer Email*

Name of End User:*

Product Model*

Product Serial Number*

Is the end user still able to use their equipment?*

Has there been any changes to the configuration?*

If the answer is Yes, please confirm what changes have occured.

Has there been any non-Permobil devices installed?*

If the answer is Yes, please confirm what devices have been installed.

When did the error occur?*

What is the frequency of concern (error/fault)*

Has the error been confirmed by a technician/dealer rep?*

How was the product being used at the time of error?*

Please confirm the environmental conditions at the time of error (humidity, rain, temp etc)*

What was the battery charge level and state of health?*

Is the wheelchair connected to MyPermobil/Fleet Management?*

If the wheelchair is not connected to MyPermobil/Fleet Management, does the user give permission to be connected?*

Have any parts been replaced prior or during the diagnostics process*

If the answer is Yes, please confirm what parts have been replaced.

Do you have any further information you wish to provide to help our technical support team diagnose the problem?

Please provide any files to support this request here:

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