Hospital Bed Intake Form

Hospital Bed Rental Intake Form
Is this a Rental Request or a Purchase Request?*
What Location is Closest to you?*
Request date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Aprox Height*
Aprox Weight*
Electric Hospital Bed
Bed Rails
Comes standard with half rails

HalfFull
Mattress
Pressure relief foam mattress- (Comes standard with all Hospital Bed Rentals)Air Mattress no Pump (Early stage of skin breakdown)Alternating Air Mattress Pressure with Pump (More compler and-or multiple areas of skin breakdowns)True Airloss Mattres with Blower
Bed Mobility
IndependentCaregiver assist with repositioning
Time on Bed
Average (8 - 12 hours)Moderate (12 - 18 hours)Significant (18 - 24 hours)
Moisture:
Additional accessories?

Fall MatFall Prevention Alarm
BedChairMagnetic Pull CardCardless
Other Notes:
Credit Card (16 Digits)
Exp
Terms and Conditions: A delivery/pickup and setup fee of $175 plus HST will apply to all rentals. For hospital bed deliveries, we require a minimum of 3 business days notice. Accommodation of 24-hour and 48-hour notice requests is possible but subject to availability based on current volume. A valid credit card is necessary to secure your rental reservation. Debit-Visa & Debit-Mastercard unfortunately cannot be used. Your credit card will be charged 24 hours prior to the scheduled delivery date. We appreciate your understanding and look forward to assisting you with your rental needs.
Signature*

Clear
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 202 - 267 O'Connor Street Ottawa, ON K2P 1V3
Should be Empty:

Hospital Bed Rental Intake Form

Electric Hospital Bed

Bed Rails

Mattress

Bed Mobility

Time on Bed

Kanata

Barrhaven

Downtown