Pants Up Easy Short Needs Assessment (2) VET Camp
  • Are you a Veteran?
  • What type of participant are you?
  • Were you aware of the VA benefit to cover your Pants Up Easy Device(s)?
    • *
      Last Name
    • *
  • Mobile or Contact Number
  • Which product are you thinking would best fit your lifestyle or environmental needs? (Multi-Pick Optional)
    • Wall Mount ($997.00)
    • Toilet Model (Frame no mounting required) ($1297.00)
    • Wheelchair Model (well built stand alone) ($1597.00)
    • Travel Model ($1697.00)
  • What are the realized benefits you see from using Pants Up Easy?
  • Where would you use your Pants Up Easy System?
  • What is your height?
  • Choose your weight
  • Do you have use of your arms and hands?
  • How is your upper body strength?
  • What type of Disability do you have? (Please check all that apply)
  • Mobility tools used? ( Please check all that apply)
  • Housing
  • Employment Status (Please check all that apply)
  • Income Range
  • Type of Insurance? (Please check all that apply)

That's all, folks!