Service Request Form*

This form is required before any service work begins — including quick fixes, tune-ups, and warranty repairs. It takes about 5–7 minutes.

Why? It lets our technician verify parts availability and prep tools before your equipment arrives, which usually means a faster repair and an accurate quote the first time.

Fields marked * are required.

Service Request Full Name

Phone Number

We'll use this to contact you about your repair request.

Product Information

Make

Model

Find the specific model online, your receipt, or who you bought from. Also, take a picture with Google and use AI to find the product.

Serial Number

Silver data plate — under the seat on scooters and power chairs, on the frame of rollators, under the seat flap on lift chairs.

Serial Number location On Battery, Frame, or Pole

Serial Number on Owners Manual

Where did you purchase?

Service Information

What's the problem? Check all that apply. 1

Won't turn on / no power

Battery or charging problem

Runs weak; slow; or cuts out

Beeping or flashing error codes

Joystick / controller issue

Brakes

Wheels; tires; or casters

Flat tire

Motor noise — grinding; clicking

Steering or tiller

Seat; upholstery; or armrests

Lift / recline not working

Hand control / remote issue

Frame damage or broken part

Folding / disassembly mechanism

General Tune Up

Not Sure - service diagnosis

Problem Description

Describe what's wrong with your Scooter, Wheelchair, Bed, or Patient Lift in as much detail as possible.

Product Condition

5 - Clean, like new condition.

1 - Considering throwing away, salvagable?

Photos of Unit

Required upload of up to 4 product images for review.

Click to choose file(s) or drag here

Size limit: 10MB per file

Any error codes, beeps, or flashing lights?🔴🟢

e.g., "9 flashes on the battery gauge" or "E5 on the display." 🔴 🔴🔴 🔴

When did this start?

Batteries last replaced?

Within the last year

1–2 years ago

2+ years / never

Did anything happen right before the problem? Check all that apply.

Nothing that I know of

Got wet or rained on

Dropped or tipped over

Collision or impact

Sat unused for a long time

Battery left uncharged

Recently transported in a vehicle

Someone worked on it

Getting it to us

How would you like service handled

I'll bring it to the showroom: Lorain Rd; North Olmsted; usually the fastest option

In-home service visit: Limited availability; trip fee applies

Cleveland HME picks it up: fees apply

Access notes for our technician

Stairs, apartment or gate codes, parking, pets — anything worth knowing before arrival.

Pricing, parts & sign-off

How our service process works:

Diagnose. A bench check confirms the actual fault — not just the symptom.
Verify parts. We call the manufacturer or distributor to confirm parts exist and get real lead times.
Quote. You get a clear written estimate — parts, labor, and timeline.
You decide. Nothing is repaired without your approval. The diagnostic fee is credited toward approved repairs.

Please confirm each of the following

Must check all boxes before we begin service.

I understand a diagnostic fee applies to all service requests and is credited toward appro

I understand parts availability is not guaranteed for equipment not purchased from Clevela

I understand Cleveland HME is a private-pay provider and does not bill insurance for service.

I understand equipment left more than 30 days after repair completion or a declined quote

The information I've provided is accurate to the best of my knowledge.

Full Name

Signature

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Date