Equipment Request - Amputees & Families Support Group QLD Inc

Name*
Phone*
Email*
Address*
State*
Postcode*
Date of Birth*
Gender*
Equipment Required*
- Wheelchair
- Walker
Comments*
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The Amputees & Families Support Group Qld Inc website is for information purposes only and does not provide specific medical advice or endorse any specific treatment, technology, company or device. Individuals are advised and to consult with their medical doctor or healthcare professional.