Rental Pre-Booking Form

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1Rental Information

2Personal Information

<img decoding="async" height="90" width="90" style="border:5px solid #D27F27; padding:3px; margin:5px; border-radius:25px" data-src="https://www.copperstarhomemedical.com/wp-content/uploads/2021/04/cs-rental_0034_WHEELCHAIR-STANDARD-16_.jpg" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://www.copperstarhomemedical.com/wp-content/uploads/2021/04/cs-rental_0034_WHEELCHAIR-STANDARD-16_.jpg" height="90" width="90" style="border:5px solid #D27F27; padding:3px; margin:5px; border-radius:25px"/>

Wheelchair — Standard 16"

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Wheelchair — Standard 18"

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Wheelchair — Standard 20"

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Wheelchair — HD 22"

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Wheelchair — HD 24"

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Wheelchair — Reclining 18"

<img decoding="async" src="https://www.copperstarhomemedical.com/wp-content/uploads/2023/04/300807.jpeg" height="90" width="90" style="border:5px solid #D27F27; padding:3px; margin:5px; border-radius:25px"/>

Wheelchair — Reclining 20"

Wheelchair — Elevating Leg Rests

Transport Chair — Standard

Transport Chair — HD

4 Wheel Walker — Standard

4 Wheel Walker — HD

Lift Chair — Standard

Lift Chair — Infinite Position Luxe

Lift Chair — HD

Power Scooter — Standard

Power Scooter — HD

Power Wheelchair — Standard

Ramp — Folding 8'

CPAP — Auto

BiPAP — Auto

Oxygen — Stationary 5L

Oxygen — Stationary 10L

Oxygen — Portable 5LB Unit (Pulse)

Oxygen — Portable 10LB Unit (Continuous)

Oxygen — Self-Fill Tank System

Heavy-Duty Suction Machine

Hospital Bed — Full Electric

Hospital Bed — Full Electric HD

Low Air Loss Mattress and Pump

Trapeze Bar

Overbed Table

Patient Lift — Standard

Patient Lift — Power

Patient Lift — Sit to Stand

Knee Walker — Standard

Knee Walker — HD

Rental Equipment*

How will you receive your rental?*

Closest Store Location*

Delivery Address

Street Address Address Line 2 City State ZIP Code

Rental Period*

Preferred Pickup Date*

Comments or Questions

Call Us

(623) 303-9697

Visit Us

5 Valley Locations

Free Consultation When You Visit Or Call

We’re conveniently located throughout the valley. Visit us today so we can help you get the relief you deserve.

Mesa Store

1155 S. Power Rd
Suite 111 Mesa, AZ 85206
(Power & Southern)
(602) 609-5554

Hours

Mon- Fri: 9am – 5:30pm
Sat: 10:00am – 4pm
Sun: Closed

Surprise Store

Formerly Valley Medical Supplies

13980 W Bell Rd, Ste 19
Surprise, AZ 85374
(Next To Kohls)
(623) 230-2741

Hours

Mon-Fri: 9am-5:30pm
Sat: 10am-4pm
Sun: Closed

Phoenix Store

Formerly Valley Medical Supplies

4030 E Bell Rd, Ste 105
Phoenix, AZ 85032
(Behind Walgreens)
(602) 900-4260

Hours

Mon-Fri: 9am-5:30pm
Sat: 10am-4pm
Sun: Closed

Goodyear Store

14175 W Indian School Rd, Ste 8
Goodyear, AZ 85395
(623) 473-5040

Hours

Mon-Fri: 9am-5:30pm
Sat: 10am-4pm
Sun: Closed

Tempe Store

2415 W Erie Dr
Tempe, AZ 85282
(602) 900-5246

Hours

Mon-Fri: 9am-5:30pm
Sat: 10am-4pm
Sun: Closed

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Preventing Infections

CMS Supplier Standard

Oxygen Equipment Instructions