1 · Your Details First name (required) Surname (required) Email address (required) Phone number (required) Preferred contact method (required) — Select —WhatsApp (Recommended)Phone callEmailSMS Number of stairlifts required (required) — Select —1234 or more Province (required) — Select —Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape City / Town (required) 2 · Your Staircase Type of staircase (required) — Select —StraightCurvedWith a landing / half-landingL-shaped (90° turn)U-shaped (180° turn)SpiralNot sure Which model are you interested in? — Select —Straight stairliftCurved stairliftOutdoor stairliftStanding / perch stairliftNot sure — please advise Distance from bottom to top of staircase (required) Measure along the wall from the bottom step to the top step, in centimetres. Number of steps (required) — Select —Fewer than 1010 – 1314 – 1617 – 20More than 20Not sure Approximate staircase width (required) — Select —Less than 70cm70 – 80cm81 – 90cm91 – 100cmMore than 100cmNot sure Where is the staircase located? — Select —IndoorsOutdoors Does your staircase have any bends, landings or turns? — Select —No — straight all the wayOne bend / turnTwo or more bends / turnsHas a landingNot sure Existing handrail position — Select —Left side (going up)Right side (going up)Both sidesNo handrailNot sure Please describe your staircase in as much detail as possible 3 · The Primary User Who will primarily use the stairlift? (required) — Select —MyselfMy spouse / partnerA parentAnother family memberA patient / client in my care Approximate age of primary user — Select —Under 5050 – 6465 – 7475 – 8485 or older Approximate weight of primary user (required) — Select —Up to 80kg81 – 100kg101 – 120kg121 – 140kgMore than 140kg Does the user currently use any mobility aids? — Select —NoneWalking stick / caneWalking frame / walkerWheelchairMobility scooterOther 4 · Your Property Type of property (required) — Select —Freestanding houseTownhouse / clusterApartment / flatRetirement village unitCare / frail-care facilityCommercial premisesOther 5 · Photos & Final Details Photos are highly recommended. Where possible please attach: a full view of the staircase, the bottom step, the top step, any curves or landings, the side wall for rail mounting, and the nearest plug point. JPG / PNG / PDF, max 5MB each. Photo 1 Photo 2 Photo 3 Photo 4 Photo 5 Photo 6 Preferred installation timeframe — Select —As soon as possibleWithin 2 weeksWithin a month1 – 3 monthsJust gathering information How soon do you need the installation? (required) — Select —Urgent (within days)Soon (within weeks)FlexibleNo fixed date yet Any additional information or questions for us? I confirm that the information provided is accurate to the best of my knowledge, and I consent to Renco Industrial using it to prepare a quotation and contact me regarding my enquiry. (required) Δ