MANUAL WHEELCHAIR & TRANSPORT CHAIRS

Name on Reservation *

First Name Last Name

Patient name if different than reservation name:

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

E-mail *

Patient Height *

Patient Weight *

Preferred Pick Up Date *

Month Day Year Hour Minutes AM/PM Option

Preferred Drop Off Date *

Month Day Year Hour Minutes AM/PM Option

To help us determine if a transport chair or full size chair is better.

	Patient will self propel	Caregiver will push the patient
Yes

Pricing on Standard Full Size Wheelchair or Transport Chair with Footrests - 250 lb weight capacity

Weekly (1 to 7 days) $50 (2) Weeks $80 Monthly $100

Pricing on Heavy Duty Transport Chair with Footrests. 400 lb weight capacity

Weekly (1 to 7 days) $85 (2) Weeks $150 Monthly $200

Pricing on Heavy Duty Wheelchair with Footrests. 350 lb weight capacity

Weekly (1 to 7 days) $85 (2) Weeks $150 Monthly $200

Pricing on Extra Heavy Duty Wheelchair with Footrests. 450 lb weight capacity

Weekly (1 to 7 days) $100 (2) Weeks $175 Monthly $225

Pricing on Elevating Leg Rests - each

Weekly $15 left Weekly $15 right Monthly $15 left Monthly $15 right

I wil pick up and drop off the wheelchair at LTC Wheelchairs

Yes

I would like a price quote on renting one of the following items:

Tilt in Space Chair High Back Reclining Wheelchair 4-Wheeled Walker 6-ft Suit Case Ramp

Message to LTC Wheelchairs staff:

Enter the message as it's shown *