Durable Medical Equipment Donation Form

1
Contact Name* This field is required.
First Name
Last Name
2
Contact Phone Number* This field is required.
Area Code
Phone Number
3
Contact Email* This field is required.
example@example.com
4
Preferred Method of Communication?
Please Select
Please Select
Phone
Email
5
Equipment Being Donated* This field is required.
6
Condition of Equipment* This field is required.
Please Select
Please Select
New
Like New
Used in Good Condition
Used in Fair Condition
7
Size of Equipment* This field is required.
Please Select
Please Select
Small
Medium
Large
8
Approximate Weight of Item * This field is required.
Please Select
Please Select
0-25lbs
25-50lbs
50-100lbs
100lbs+
9
Additional Concerns/Comments
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: