Vision Mobile

Was this job completed successfully?

Yes

Notes:

Photos:

Serial Number:

Package Number:

Have you collected anything, or replaced any parts?

Yes No

Are any parts required?

Yes No

If yes, please give details:

Have you taken any money?

Yes No

If yes, please give details:

Customer Satisfied:

Yes No N/A

Please ask the customer to rate the service they have received today:

Appointment Time Taken:

Further Visit Required:

Yes No N/A

I declare that I am chronically sick or disabled and that I am receiving the said goods being supplied to me for my personal use, and claim that the supply of these goods is eligible for relief from VAT under group 12 of Schedule 8 of the Value Tax Act 1994. I also confirm that I have read the Engineers Report. If further work is required, I have been advised of the next steps in the process.

Type of Disability:

I confirm that I have received a copy of the terms and conditions and my cancellation rights:

Yes No

Customer Signature

Clear

Requirements Section

Repair Reason 1:

Attach Photo (Part 1)

Repair Reason 2:

Attach Photo (Part 2)

Repair Reason 3:

Attach Photo (Part 3)

Controller Type:

Flash Code:

Product Images

Attach Photo (Front View)

Attach Photo (Rear View)

Attach Photo (Side View 1)

Attach Photo (Side View 2)

Voltage Reading On Load:

Voltage Reading Off Load:

Charger Checked & Fuse:

If No, please give details:

Confirmation of Repair

Repair Complete:

If No, please give details:

Further Resolution to the Vehicle:

Parts required, if any:

Scooter To be taken of Site Due to Lack of:

Notice - This app is scheduled to be decommissioned on Monday 23rd September 2024. Please ensure you move to the new Vision app before that time.

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Notes:

Environment:

Maintenance:

Condition:

Product Handover - Chair / Bed

1. I have received the owner's manual and its contents have been explained to my satisfaction

Yes No N/A

2. The chair/bed has been placed in a suitable position in my home for me to use

Yes No N/A

3. I have been shown how to attach the power supply to the chair/bed and plug it in to the mains

Yes No N/A

4. I have been shown how to operate the chair/bed using the hand control

Yes No N/A

5. The battery backup system has been fully explained to me

Yes No N/A

6. I have been shown how to raise the chair/bed to the stand position

Yes No N/A

7. I have been shown how to recline the chair/bed to the fully reclined position

Yes No N/A

8. I have been shown how to operate the rise & recline chair/bed safely. I understand that I can refer to the owner's manual for further information on safety, operation and maintenance.

Yes No N/A

9. Has any of your property, fixtures or fittings been damaged in any way while our engineer has been present?

Yes No N/A

10. I acknowledge that the rise & recline chair/bed has been received in good condition and in good working order.

Yes No N/A

Notes:

Environment:

Maintenance:

Condition:

Product Handover - Scooter

1. I have received the owner's manual and its contents have been explained to my satisfaction

Yes No N/A

2. The battery charging procedure has been explained, I understand that I must charge the battery for 8-12 hours after each use, the key must be removed, and if applicable I will leave the battery on charge for 24 hours before initial use.

Yes No N/A

3. I understand I must not charge my battery with a different charger to the one provided with the scooter.

Yes No N/A

4. I have been shown how to operative the key ignition, lights, hazard lights, indicators and horn (where applicable)

Yes No N/A

5. I have been shown how to use forward and reverse throttle controls

Yes No N/A

6. I have been shown how to adjust the speed and that 8mph EPV must be set at 4mph max for use on pavements (where applicable)

Yes No N/A

7. I have been shown how to use forward and reverse throttle controls

Yes No N/A

8. I have been shown how to brake safely using the automatic braking system (including handbrake on 8mph models if fitted)

Yes No N/A

9. I have been shown how to dismantle the mobility aid (where applicable)

Yes No N/A

10. I have been shown how to use the free wheel mechanism

Yes No N/A

11. I have had the seat adjusted so that I am in a comfortable position

Yes No N/A

12. All of the above have been demonstrated, and tried so that I am comfortable of use

Yes No N/A

13. I agree that I have been shown how to operate the mobility scooter safely. I understand that I can refer to the owner's manual for further information on safety, operation and maintenance.

Yes No N/A

14. I am able to move the mobility scooter from my property storage area to my property exit

Yes No N/A

15. I have been taken for a test drive which lasted 5 minutes

Yes No N/A

16. Has any of your property, fixtures or fittings been damaged in any way while our engineer has been present?

Yes No N/A

17. I acknowledge that the mobility scooter has been received in good condition and in good working order.

Yes No N/A

Notes:

Environment:

Maintenance:

Condition:

Service Certificate

1. Battery Capacity Test

OK Not OK N/A

2. Battery Charger Tested

OK Not OK N/A

3. Motor Brushes Checked

OK Not OK N/A

4. Motor Drawn and Checked

OK Not OK N/A

5. Motor Brake Checked and Cleaned

OK Not OK N/A

6. Check Electric leads for chaffing and Wear

OK Not OK N/A

7. Console: All Functions Working Correctly

OK Not OK N/A

8. Check Tightness of Nuts and Bolts

OK Not OK N/A

9. Wheel Bearings Checked

OK Not OK N/A

10. Tyres/ Rims: No Visible Damage

OK Not OK N/A

11. Check and Lubricate Lubrication Points

OK Not OK N/A

12. Front Brake (where fitted) Operates Correctly

OK Not OK N/A

13. Seat: All Functions Working Correctly

OK Not OK N/A

14. Steering Column Set Correctly

OK Not OK N/A

15. Fully Cleaned and Valeted

OK Not OK N/A

16. Test Drive: All Functions Working

OK Not OK N/A

17. Test Drive: No Undue Vibration or Noise

OK Not OK N/A

Additional Information:

Action to be Taken:

Notes:

Environment:

Maintenance:

Condition:

Service / Repair Order

Work Carried Out:

Other Action to be Taken:

Service / Repair Order

Initial Assessment

Customers Weight (Stone):

Environment:

Locality:

Maintenance Of Product:

Primary Use:

Storage:

Opinion of Repair:

Glass / Mirrors / Bodywork
Front & Rear Sidelights and Foglights
Headlights Main and Dipped Beam
Brake Lights and Reversing Lights
Horn, Wipers and Washers
Numberplate Visibility and Rear Light
Wheel Damage

Front:
Rear:
Driver:
Passenger:

Engine Oil Level / Coolant
Water / Oil / Fluid Leaks
Washer Fluid / Brake Fluid

Seat Belts Operation
Handbrake Operation
Dashboard Warning Lights