Provider Education Request Form

Please fill out the form below to make a training request.

Account Information

Account Name:

Account #:

Account Address:

Contact Person:

Contact Email:

Contact Phone:

Additional Comments:

Type of Training being requested: (Please check all that apply)


(Please include model number and/or service history on the unit if applicable)

Nature of Training Request:

Basic Information:

Preferred date(s):

Preferred time(s):

Location of CE/T Activity (city/state):

Anticipated Number of Attendees:

Target Audience: (Please check all that apply)

Questions regarding any specific training classes may be submitted to Please allow 48 hours for a response.

** Fees may apply, as we need to cover organizational management and travel costs. Final cost, if applicable, will be provided by the Education Department.

About Quantum Rehab

Quantum Rehab® was born out of the desire to delight customers with the most advanced, consumer-inspired complex rehab power wheelchairs and related technologies possible.

At Quantum, consumer needs and wishes are the driving force. We’re dedicated to not just meeting medical and clinical needs, but also quality-of-life needs. From the most advanced power seating for pressure management to USB ports, Bluetooth and fender lights, no consumer need is overlooked.

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Quantum Rehab
401 York Avenue
Duryea, PA 18642

1-833-QiLevel (745-3835)

Monday - Friday
8:30am - 5:00pm ET