ONLINE REQUEST FORM
Walkers | Wheelchairs & Accessories | Hospital Beds & Lifts | Mobility Scooters | Accessibility Equipment | Bathroom Aids
Today's Date or next business day
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date being requested for
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Month
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Day
Year
Date
Length of time being requested
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All our rentals autorenew on a 4-week basis
Tell us a little bit about what you are looking for. Please be as detailed as possible
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What are you looking for today?
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Wheelchairs & Accessories (Includes Optional ramps and accessories)
Walkers (Includes Optional ramps and accessories)
Bathroom Aids
Mobility Scooters (Includes Optional ramps and accessories)
Accessibilities - Ramps (Only ramps)
Hospital Beds (Includes Optional Lifts)
Lifts & Sliding boards & Vitrectomy (lifts and Vitrectomy only)
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Hospital Beds
Choose One
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Home Care Beds
Long Term Care Beds
Bariatric Beds
Prime Care Model Beds
Other
Do you need a Lift?
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Yes
No
Lifts & Transfer Equipment & Accessories
Choose what you require
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Lift U Base
Electric Power Lift
Unversal Sling
Superpole
Sliding Board
Standing Trapeze
Vitrectomy Face-down recovery chair
Victrectomy Face-down recovery tabletop and mattress system
Vitrectomy Face-down pillow
I do not want any lifts or accesories
Bathroom Aid
Choose One or Both
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Transfer bench
Commode
None
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Walkers
Choose One or Both
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4-point walker
Rollators
Will you need a ramp or accessibility items?
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Yes
No
Wheelchair Rental
Choose One
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Manual Folding Wheelchair
Transport Wheelchair
Manual Tilting Wheelchair
Power / Electric Wheelchair
Unit of Measurement
Please Select
Inches
Centimeters
1) Chair Width
2) Chair Depth
3) Seat to Floor Finished
4) Foot Rest Length
5) Back Rest Height
6) Back Rest Width
7) Arm Rest Height
8) Head Rest Height
Will you need Wheelchair Accessories?
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Yes
No
Will you need a ramp or accessibility items?
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Yes
No
Wheelchair Accessories
Choose all accessories required
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Amputee Board
Back Support
Cushions
Elevating Leg Rests
Oxygen Holder
Lap Tray
Dynamic Tilt
Brake Extension
4-point seat belt
I don't want any accessories
Other requests?
Mobility Scooter Rental
Choose the size of scooter
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Small - Mid Size
Mid SIze - Heavy Duty
Will you need a ramp or accessibility items?
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Yes
No
Accessibilities
Do you require accessibility items?
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Stair Lift
Modular Ramp
Threshold Ramp
Folding Ramp
I don't want a ramp
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Please verify that you are human
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