Rental Pre-Booking Form

"*" indicates required fields

Standard Wheelchair - 16"

Standard Wheelchair - 18"

Standard Wheelchair - 20"

HD Wheelchair - 22"

HD Wheelchair - 24"

Elevating Leg Rests

CPAP - Machine

Portable Oxygen Concentrator - Continuous

Portable Oxygen Concentrator - Pulse Dose

Home Stationary Oxygen

Power Scooter - Standard

Power Scooter - HD

Heavy Duty Lift Chair

Standard Lift Chair

Hospital Bed - Semi Electric

Heavy Duty Mattress

Overbed Table

Trapeze Bar

Knee Walker

Patient Hoyer Lift

Rental Equipment Needed*

How will you receive your rental?*

Closest Store Location*

Rental Period*

Delivery Address

Street Address Address Line 2 City State ZIP Code

Preferred Pickup Date*

Please note: We are closed on holidays. Rentals are not available on 9/1, 11/27–11/28, 12/25, 1/1, 5/26, and 7/4.

Comments or Questions

Name*

First Last

Email*

Phone*

Your Height*

Your Weight*

No Solicitation Please

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Comments

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