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Bikes & Trikes Form

Adaptive bicycles and tricycles are a great way to get active outdoors. Riding the one that isn’t the right size, however, can be a frustrating experience that can quickly put the brakes on an afternoon of fun.

This form is designed to guide you through the process of finding the measurements needed to ensure comfort, function and room for growth, as well as ask important questions related to the bicycle or tricycle you’re interested in. Once submitted, our customer service representatives will look over your information and send a list of suggested products and accessories that fit your needs.

First Name *
Last Name *
Organization
Title
Address *
City *
State/Province *
Country *
Zip/Postal Code *
Phone *
Fax
Email *
Yes, I would like to receive eNews from eSpecial Needs
What is his/her overall height?
What is their overall weight?
Age?
Model of Bike/Trike?
Bike/Trike Style:
Can he/she pedal on their own?
YesNo
Can the he/she steer on their own?
YesNo
Does he/she require head support?
YesNo
Does he/she require trunk support?
YesNo
Are foot plates with heel cup and/or foot straps required?
YesNo
Is tray needed?
YesNo
Is storage basket needed?
YesNo
Is a push/pull bar needed for caregiver to assist with tricycle?
YesNo
What other type of support will user require?
     Measurement
L - Groin (Inside of Leg) to Floor
M - Hip Bone To Bottom Of Foot