OT Equipment Request Form

1

Click here to check what items are available before proceeding: Inventory

2

I'm requesting equipment for* This field is required.

3

Contact Name* This field is required.

First Name

Last Name

4

Contact Email* This field is required.You will be contacted via email about equipment availability and pick up directions.

example@example.com

5

Contact Phone Number* This field is required.You will be contacted via email about equipment availability and pick up directions.

Area Code

Phone Number

6

What is the best way to contact you?* This field is required.

7

Is the user...* This field is required.

8

How much does the user weigh?* This field is required.

9

How tall is the user?* This field is required.

11

Is there a specific addition to the piece you are looking for? (Like seat cushion or elevating leg rest for example)* This field is required.

12

Is there a piece of equipment that will best suit your needs from the inventory? Please list all of the item numbers from the inventory list that you would like to request.