Rental Form

⚠️ Important Fourth of July Notice Due to the high demand for the Fourth of July holiday, mobility scooters are booking quickly. We will do our best to provide the scooter you requested. If that model is unavailable, we may substitute a comparable scooter to ensure you have mobility equipment for your trip. Thank you for your understanding and flexibility during this busy holiday period.

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

Date

Hour MinutesAM/PM Option

Rental end

Date

Hour MinutesAM/PM Option

User Full Name

Has the user used a scooter before

Type of mobility scooter 3 wheel or 4 wheels

Height

Weight

Where are you using the Mobility scooter or the Electric wheelchair

Are you transporting the scooter in a vehicle?

How did you here about us?

Additional Comments and questions

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

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

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

🛡️ 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 – $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
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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. ✅ Fees are non-refundable and must be added before delivery.

$30.00 Quantity
Item subtotal:

Tip

Thank you so much for the tip. Orthopaedic Mobility Rentals

$5.00 TipTip

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