MANUAL WHEELCHAIR & TRANSPORT CHAIRS

Name on Reservation

First NameLast Name

Patient name if different than reservation name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Patient Height

Patient Weight

Preferred Pick Up Date

MonthDayYearHourMinutesAM/PM Option

Preferred Drop Off Date

MonthDayYearHourMinutesAM/PM Option

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

Rows	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

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

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

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

Pricing on Elevating Leg Rests - each

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

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

Message to LTC Wheelchairs staff:

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