If you’d like to request service or modifications to a piece of equipment NOT provided by Custom Mobility Inc, please fill out the following online questionnaire. After you submit your request, we’ll process it and get back to you as quickly as possible.

Click the blue "Continue" button below to get started.

Please complete the required minimum fields that have an * next to them, then click the blue "Submit" button.

If you are unable to view the Customer Service Questionnaire in your browser or mobile device, you may click here to view and download the form. Please print and fax the completed form to: (855) 834-7315