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	After you submit this form, an Orbit Medical mobility specialist will call you or your loved one for a free no-risk phone consultation. We will help you find out if you qualify for an electric wheelchair at little or no cost to you. If you are a good candidate, then we will handle all of the insurance paperwork so that you don't have to.
	**By submitting this form, you agree to allow Orbit Medical to use the supplied contact information to contact you about products and services provided by Orbit Medical and its partners.