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Website Questionnaire

Listen Up!

Listening to what you have to say is a big part of our on-going customer support. Take a few minutes to complete the following questionnaire and you'll be entered into our free prize draw to win a pair of urBeats in-ear headphones by Dr Dre.

We'll listen to you and you can listen in style!

Please complete all sections... Good Luck!

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How did you find us?
Where did you hear about us? (required)
If "Magazine Advert" please state which magazine
If "Other", please specify
How did you find our website? (required)
If "Other", please specify
What is your reason for visiting our website? (required)

How was our website?
Did you find what you were looking for?
If No, please tell us what you couldn't find?
Do you find our website user friendly?
Have you visited www.gerald-simonds.co.uk before?
Have you visited www.gerald-simonds.co.uk?
Have you visited www.suchgoodsports.co.uk?

Products and Services

What products or services are you interested in? (required)

Lightweight Rigid Wheelchairs
Lightweight Folding wheelchairs
Powered wheelchairs
Stand up wheelchairs
Childrens wheelchairs/seating
Add on Powerdrives
Sports wheelchairs
Mobility Scooters
Drive Controls
Tilt and Recline
Seating / pressure area care
Servicing / technical support
Aids to Daily living
Other Product or Service
If "Other", please specify


Which brands are you interested in?

Active Controls
Sunrise Medical
Other Brand
If "Other", please specify

About you
Which of the following relates to you? (required)
What is your disability? (required)
If "Other", please specify

About your wheelchair
What type of wheelchair do you currently use?
If "Other", please specify
Please tell us the Model / Brand
Do you have a Specialist Wheelchair Cushion or Back?
Please tell us the Model / Brand

Shows and Exhibitions
Have you ever visited a mobility exhibition such as the Mobility Roadshow? (required) If Yes Please tick which ones...
Mobility Roadshow
Naidex National (NEC)
Naidex South (Excel)
Kidz up North/Middle/ South
Beyond Boundaries
No Limits
Other Show or Exhibition
If "Other", please specify

What are your interests / hobbies?
Outdoor Activities
Social Networking
Other Interests
If "Other", please specify
Do you take part in any wheelchair sports / activities? (required)
If "Yes" please specify which ones

You and the press
Do you read any of the following Disability Magazines? (required) If Yes Please tick which ones..
SIA Forward
MS Matters
Disability Now
Target MD
If "Other", please specify

Enter the draw...

Thank you for completing our questionnaire.
In order to be entered in to the free prize draw, please provide the following details.

Title: First Name Surname:
Email Address (required)

We'd like to keep in touch after we have fulfilled this request. Please let us know if you would like to receive updates on products and services, by selecting one of the boxes below

Your Privacy

Gerald Simonds Healthcare Ltd. is committed to protecting your privacy and will never sell your details to other companies. Please refer to our Privacy Policy here for more details.

All details supplied to us will be treated confidentially and will not be disclosed to any third party.
Please use this space to give further details of the answers given above, or to add any other comments:
Please enter the characters shown to verify your submission.

Winners will be announced on our website and contacted via e-mail to arrange delivery. Good Luck!

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