Online Reservation Form

To place your order online, please fill in the following form. Upon receiving your reservation, a Care Chairs representative will contact you to confirm details and schedule your delivery!

Please complete the following form:

Personal Information

Full Name:
Home Address:
City:
Province:
Postal Code:
Home Phone:
Business Phone:
Mobile Phone:
E-mail address:
Retinal Surgeon:
Hospital:
Date of Operation:

Delivery Information

Same as Above:	Yes No
If No,
Location Name:
Address:
City:
Province:
Postal Code:
Phone Number:

Equipment Required (Please mark box)

Health Mark Pro Massage Chair with MajicView Mirror™

The M.A.T.™

Prism Glasses

Date of Delivery:		Preferred Time:
Date of Pick-up:		Preferred Time: