Los Angeles Pediatric DME Request Form
Your Name
First Name
Last Name
Relationship to Child in Need of Equipment
Please Select
Parent
Caregiver
Other Family Member
Teacher
Other
Your Email
example@example.com
Your Phone
Please enter a valid phone number.
Child Name (optional)
First Name
Last Name
Child Height
Child Weight
Type of Requested Equipment
Stander
Gait Trainer
Walker
Activity/Feeding Chair
Bath Chair
Adaptive Bike
Wheelchair
Vibration Plate
Canes
Other
Please provide additional detail of your request (brands, sizing, product features, etc.)
Submit
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