Your Full Name
*
Phone Number
*
Preferred Method of Returning Equipment
*
Drop-off
Pick-Up
Pick-up Address
*
Street Address Line 2
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Equipment Being Returned
*
Wheelchair
O2 Concentrator
Hospital Bed
O2 Tank
Hoyer Lift
Boot
Rollator
Crutches
Cane
Knee Scooter
Walker
Medical Recliner
Pediatric Scooter
Pediatric Walker
Pediatric Wheelchair
Raised Toilet Seat
Shiva Equipment
Commode
Ramp
Shower Chair
Transport Wheelchair
Other
Access & Placement Instructions
(Floor level, entry Notes, etc.)
Additional Comments:
Office Email
example@example.com
Submit
Should be Empty: