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Equipment Request Form
Please fill out this form to request a piece of equipment. Users are only allowed to rent up to 3 pieces of equipment at a time.
14
Questions
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1
Email
*
This field is required.
example@example.com
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2
I have checked the inventory before proceeding:
Inventory
*
This field is required.
YES
NO
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3
Input contact information for...
*
This field is required.
Please Select
Myself - I am the equipment user
Family Member
Myself - I am the carer of the equipment user
Someone Else
Please Select
Please Select
Myself - I am the equipment user
Family Member
Myself - I am the carer of the equipment user
Someone Else
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4
Contact Name
*
This field is required.
First Name
Last Name
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5
Contact Email
*
This field is required.
example@example.com
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6
Contact Phone Number
*
This field is required.
Area Code
Phone Number
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7
What is the best way to contact you?
*
This field is required.
Please Select
Email
Phone
Please Select
Please Select
Email
Phone
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8
Is the user...
*
This field is required.
Please Select
Infant
Child
Teen
Adult
Geriatric
Please Select
Please Select
Infant
Child
Teen
Adult
Geriatric
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9
How much does the user weigh?
*
This field is required.
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10
How tall is the user?
*
This field is required.
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11
What type of equipment are you looking for?
*
This field is required.
Bed Side Commode
Cane
Miscellaneous
Patient Lift Device
Pediatric Stander
Rollator
Shower Chair
Walker
Wheelchair
Other
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12
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.
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13
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.
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14
List estimated start date, of use
*
This field is required.
/
Date
Month
Day
Year
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15
List estimated end date, of use
*
This field is required.
The UMHB DME program limits the length of a loan to one year.
/
Date
Month
Day
Year
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