Rental Form

🕒 DELIVERY HOURS

We deliver Monday–Friday, 6:00–8:00 PM, and Saturday–Sunday, 10:00 AM–5:30 PM. For hotels, delivery is usually the evening before check-in. For Airbnb stays, we’ll coordinate by text or email. National Mall and museum deliveries are available weekends only.
Name*

First NameLast Name
Company Name
Email*
example@example.com
New Customer
Mobile Number *
Please enter a valid phone number.Format: (000) 000-0000.
Type of Equipment
Delivery Address and hotel name
Where are you staying
Reservation Under name
Rental start

MonthDayYear
Date
Hour MinutesAM/PM Option
Rental end

MonthDayYear
Date
Hour MinutesAM/PM Option
User Full Name
Height
Weight
Where are you using the Mobility scooter or the Electric wheelchair
Were you referred by a hotel staff member? If yes, please write their name and hotel name.
Additional Comments and questions
🛒 How to Order

1️⃣ Scroll down to see available equipment.2️⃣ Tap the box ✅ next to the item you want to rent.3️⃣ Choose your rental duration and quantity.4️⃣ Click “Pay Now” 💳 to complete your order.💡 Tip: You can select more than one item before checkout.

Jazzy elite wheelchair Rental 3

Weight Capacity = 300lbs Drive Range = 7-10 Miles Indoors

$150.00 Rental durationQuantity

Electric wheelchair Rental

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

$150.00 Rental durationQuantity

Permobil F3 Electric wheelchair Rental

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

$185.00 Rental durationQuantity

🛡️ 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• ✅ If you decline this plan, you’ll be fully responsible for repair, loss, or replacement costs during your rental.

$50.00 Quantity

📅 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. ✅ Fees are non-refundable and must be added before delivery.

$30.00 Quantity

Tip

Thank you so much for the tip. Orthopaedic Mobility Rentals

$5.00 TipTip

Transportable Gogo chair

Weight Capacity = 300lbs Drive Range = 4-7 Miles Indoors and Outdoors

$150.00 Rental durationQuantity

Enter coupon

Subtotal

$0.00

Tax

$0.00

Shipping

$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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🕒 DELIVERY HOURS

🛒 How to Order