Rental selector form

Customer Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Which hospital or care facility?* This field is required.

Department or ward?* This field is required.Where is the equipment to be delivered?

Wheelchairs

Tilt in space wheelchair

Self propelled wheelchair, 18" seat width

Self propelled wheelchair, 20" seat width

Self propelled wheelchair, 22" seat width

Car transit wheelchair

Heavy Duty Wheelchair, 25" seat width

Shower commode chairs

RAZ AT Bariatric

RAZ AT Paediatric

CM-Aqua Tilt in Space

Tilt in Space Shower Commode with Recline

CMD200 Deluxe Commode

CMD200 Deluxe Commode (Self-propelled version)

Extra-Width Shower Commode - Static (seat width - 61cm)

Extra Width Shower Commode - Wheeled (seat width - 61cm)

Seahorse Paediatric

CMD100

Bathing

Manual Shower trolley

Turtle Bath Support

Paediatric Turtle vacuum support cushion, size 2

Bariatric & Recliner Chairs

TX30 Manual

Contour Recline chair

Bariatric Ward chair, 60cm / 24" wide

Extra large bariatric ward care chair to rent (SWL 350kg)

Tilt Tables

Standard Tilt Table

Deluxe Tilt Table

Standing Aids

Sara Stedy

Move Assist

ReTurn

Specialist Seating

CH5-S - 160kg

CH5-L - 250kg

CH5-S + Laterals

CH5-S with Wings

Sertain S/L/XL

Portering Chair - 300kg

TX Chairs - 180kg /190kg

Beds

EN7 - 200-300kg

2400 Bariatric Profiling Bed - 400kg

Patient sizingNot all dimensions may be needed.

Patient weight in KG

Seat width required (cm)

Seat depth required (cm)

Legrest height (edge of seat to footplate) (cm)

Backrest height (cm)

Headrest height (shower commodes / Azaleas) (cm)

Facility specific questions(For regular rental clients, this info is not required)

Ground floor restrictions: steps, ramps, doorway widths?

If above or below ground floor, i.e. 1st floor or basement, any lift restrictions - widths / lengths esp. for larger kit?

Opening hours or access restrictions?

Parking restrictions or ParkingEye removal requests?

Best site contact on delivery day

Direct phone number

Patient transfer (Where applicable)Any special conditions for transfer?

Lateral / pat-slide

Hoist / passive

Ambulant (self-transfer)

Hoist / standing / stand-aid

Transfer aid (i.e. move-assist or Arjo Stedy)

Options / accessoriesTick all that apply. If not shown, please use the notes section that follows

Head support / headrest

Laterals / thoracic supports

Safety belt

4-point chest harness

Elevating legrests

Specialist seat cushion (very high risk)

Gel arm pads(for shower chairs)

Side rails for beds (incl. bumpers)

Any other options / accessories not listed above?

Approx. rental durationThis is just a guesstimate. The minimum rental period is 7 days.

Rental selector form