Achiezer Equipment Division RETURNS

Your Full Name*
Phone Number*
Preferred Method of Returning Equipment*

Drop-offPick-Up
Pick-up Address*

Street Address Line 2
Equipment Being Returned*

WheelchairO2 ConcentratorHospital BedO2 TankHoyer LiftBootRollatorCrutchesCaneKnee ScooterWalkerMedical ReclinerPediatric ScooterPediatric WalkerPediatric WheelchairRaised Toilet SeatShiva EquipmentCommodeRampShower ChairTransport WheelchairOther
Access & Placement Instructions
(Floor level, entry Notes, etc.)
Additional Comments:
Office Email
example@example.com
Should be Empty: