Adaptation Questionnaire

Let us know about your needs so we can better help you.

Please indicate which area(s) you’re having difficulty with(*)

Please indicate which area(s) you’re having difficulty with Driving a vehicle
Accessing a vehicle
Stowing a mobility product in a vehicle
Other

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Please Describe(*)

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Have you had a driving assessment to determine which adaptation(s) may be suitable for you?(*)

Have you had a driving assessment to determine which adaptation(s) may be suitable for you? Yes
No
Awaiting assessment

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Please advise the nature of your disability/medical condition, and how it affects you:(*)

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Please provide details of your mobility product (if applicable)

Type of Product

Type of Product Scooter
Powerchair
Wheelchair

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Make

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Model

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Please provide details of your car, or the car you’re considering purchasing/leasing

Make

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Model

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Year

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Body Style

Body Style Hatchback
Estate
SUV
MPV

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Name(*)

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Postcode(*)

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Email(*)

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Phone(*)

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Contact

01377 252500
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Driffield Mobility
Scotchburn Garth
Skerne Road
Driffield
East Riding of Yorkshire
YO25 6EF

Driffield Mobility

We specialise in vehicle adaptations for disabled drivers & passengers. A well established company, we have been providing vehicle adaptations to customers in the UK for over 22 years, developing a solid reputation in the process.