Rental Agreement
What location is this being requested?
Please Select
Kanata
Barrhaven
Centrepoint - Downtown
Home - Delivery
Request date
*
-
Month
-
Day
Year
Date
What is being requested? Please choose as many as apply.
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there an Occupational Therapist or Physiotherapist for your care?
Please Select
Yes
No
Therapist information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Credit card information
*
Expiry:
*
Type a question
Visa
Mastercard
*Client will be billed automatically for the next rental period on late returns. Rental starts on day of pick up
** All rentals are subject to full charge of their MSRP price in the event there is smoke damage to our equipment. Smoke damage will deem the products unrentable and unusable.
Signature
Submit
Kanata
Hazeldean Mall 17 - 300 Eagleson Road Kanata, ON K2M 1C9
Barrhaven
Medical Centre 205 - 16 Green Street Nepean ON K2J 3R2
Downtown
The Doctor's Building 120 - 267 O'Connor Street Ottawa, ON K2P 1V3
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