Matt's Local Pharmacy Medical Equipment Rental Form

Equipment Rental Service is limited to Middletown, Newport, Jamestown and Portsmouth areas in Rhode Island
- Name*
  
  First NameLast Name
- E-mail*
- Phone Number*
  
  Area CodePhone Number
- Location*
  Hotel Name or Home including Address
- 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 $0.00Tax $0.00Total $0.00
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- Time
  
  :HourMinutesAM/PM Option
- Additional Details
  Any special instructions or delivery information
- The PayPal Checkout below includes the option to use Credit / Debit Cards
  
  Click on PayPal Checkout to open the payment window
- Please Note: In addition to this request process a standard equipment rental agreement will be completed as part of this rental processs
- Payment Methods
  
  Choose from one of the PayPal options to make your payment.
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Equipment Rental Service is limited to Middletown, Newport, Jamestown and Portsmouth areas in Rhode Island