Rental Form

Name

First NameLast Name

Email

example@example.com

New Customer

Mobile Number

Please enter a valid phone number.Format: +1(000) 000-0000.

Type of Equipment

Delivery Address and hotel name

Where are you staying

Reservation Under name

🏖️ Vacation Notice

Orthopaedic Mobility Rental will be closed for our annual vacation August 10–16, 2026. During this time, we will be unable to make deliveries, pickups, or accept new rentals.

We apologize for any inconvenience and appreciate your understanding. We look forward to serving you before or after our vacation.

Rental start

Date

Hour MinutesAM/PM Option

Rental end

Date

Hour MinutesAM/PM Option

User Full Name

Type of mobility scooter 3 wheel or 4 wheels

Height (ft & in)

Enter feet and inches, like 5'8".

Weight (lb)

Enter weight in pounds, like 160.

Where are you using the Mobility scooter, Electric wheelchair.

Are you transporting the scooter in a vehicle?

How did you hear about us?

Additional Comments and questions

Gogo Plus 3 or 4 Wheels Transportable Scooter Rental (Disassemble in 3 pieces)

Weight Capacity =300 lbs. Drive Range = 7-12 miles of travel per charge based on average use by a 125 LB person on a flat surface.

$150.00 Rental durationQuantity
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National Mall 1 Day Full Scooter Rental

Weight Capacity = 400lbs Drive Range =15-20 miles of travel per charge based on average use by a 175 LB person on a flat surface. Saturdays and Sundays only.

$150.00 Rental durationQuantity
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Victory 10 Full scooter 3 or 4 wheels Rental

Weight Capacity = 400lbs Drive Range = 15-20 miles of travel per charge based on average use by a 175 LB person on a flat surface. Miles

$150.00 Rental durationQuantity
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Foldable Transport Wheelchair Rental (weight 25lbs)

Weight capacity Up to 300 lbs.

$100.00 Rental durationQuantity
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Foldable Manual Wheelchair Rental (weight 36lbs)

Weight capacity Up to 350 lbs.

$100.00 Rental durationQuantity
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Electric wheelchair Rental

Weight Capacity = 350lbs Drive Range = 7-10 Miles

$150.00 Rental durationQuantity
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Rollator/Walker Rental

Weight capacity Up to 500 lbs.

$100.00 Rental durationQuantity
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Bariatric Heavy-Duty Extra Wide Wheelchair Rental (weight 75lbs)

Weight capacity Up to 700 lbs.

$150.00 Rental durationQuantity
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Pediatric Foldable Wheelchair Rental (weight 29lbs)

Weight capacity Up to 200 lbs.

$106.00 Rental durationQuantity
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Knee Scooter Rental

Knee scooter rental please note model might be different when deliver.

$100.00 Quantity

Equipment Protection Plan (EPP) Optional

Protect your rental from accidental damage, loss, or theft during your rental period.✅ Covers: Small part replacements, theft (with a police report within 48 hours).⚙️ ✅ Deductible:• Scooters & Power Chairs – $250 per incident• ✅ Manual/Transport Wheelchairs, Walkers, Knee Scooters – $50 per incident. ✅ If you decline this plan, you’ll be fully responsible for repair, loss, or replacement costs during your rental.

$50.00 Quantity
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📅 Cancellation Protection Plan (CPP) Optional

Add peace of mind to your reservation — protect your rental if plans change. ✅ CPP Plus ($30): Full refund if canceled before delivery (minus CPP fee). ✅ CPP Basic ($10): Partial refund if canceled 7+ days before delivery. 🚫 No refunds after the scheduled delivery date.

$30.00 Quantity
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Tip

Thank you so much for the tip. Orthopaedic Mobility Rentals

$5.00 TipTip
Item subtotal:

Enter coupon

Subtotal

Tax

Shipping

Total

Signature – By signing below you agree to the Orthopaedic Mobility Rentals terms and rental agreement.

Payment Methods

Debit or Credit Card

🕒 DELIVERY HOURS

🛒 How to Order

Payment Methods