Matt's Local Pharmacy Medical Equipment Rental Form

Equipment Rental Service is limited to Middletown, Newport, Jamestown and Portsmouth areas in Rhode Island

Please click here to fill in the required information
Name *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Location *
Hotel Name or Home including Address

Please click here to display list of available equipment
My Products
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Wheelchair Daily Rental $ 30.00
Product Information Medline K4 Lightweight Wheelchair with Swing-Back Desk-Length Arms and Elevating Leg Rests, 18in. W Seat, One 38-inch high wheelchair has a durable, tig-welded frame; foldable, lightweight design weighs just 31.5-lbs. making it ideal for on-the-go use Comfortable, easy-care nylon upholstery wipes clean; padded armrests and calf rests for comfort Swing-back, desk-length arms with flip back arm release for easy in/out Detachable elevating leg rest to help prevent swelling and comfortably relieve pressure; back adjusts 16-18 inches Smooth-rolling solid flat-free latex tires18in. W x 16in. D seat; 8in. front casters, 24in. rear wheels300-lb. weight capacity Black hammer tone frame with black upholstery

Number of days

Crutches Daily Rental $ 10.00
Rented as a pair

Number of Days

Delivery / Pickup Fee $ 10.00
This is an optional service There is no charge for the pickup of rental medical equipment Pickup location is 88 East Main Rd Middletown RI 02842 401-619-5020 Equipment returns must be made before store closing Hours M-F 8:30am-7:30pm Saturday 9:00am - 5:00pm Sunday 10:00am - 2:00pm

Quantity

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

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Please click here to set time of day for your delivery or when you want to pickup equipment
Time

: Hour Minutes AM/PM Option
Additional Details
Any special instructions or delivery information
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Please Note: In addition to this request process a standard equipment rental agreement will be completed as part of this rental processs

Payment Methods

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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