Rental Pre-Booking Form

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"*" indicates required fields

1Rental Information

2Personal Information

Wheelchair — Standard 16"

Wheelchair — Standard 18"

Wheelchair — Standard 20"

Wheelchair — HD 22"

Wheelchair — HD 24"

Wheelchair — Reclining 18"

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 — Luxury

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

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