Referral Form

By submitting this form, you confirm that you have obtained consent from the individual named on this form to:
1. Share their personal information with Home Stairlift;
2. Allow Home Stairlift to contact them for the purpose of providing additional information about its products and services (with no obligation to purchase); and
3. Permit Home Stairlift to disclose to you whether or not the individual chooses to proceed with the service.

Confidentiality Notice:
This fax/email and any accompanying documents are intended solely for the use of the designated recipient(s) and may contain confidential and privileged information.