Achiezer Equipment Division DONATIONS

Your Full Name*
Phone Number*
Email
Preferred Method*

Drop-offPick-Up
Pick-up Address*

Street Address Line 2
Access & Placement Instructions
(Floor level, entry Notes, etc.)
What Type of Equipment Would You Like to Donate?*

Flood EquipmentBootCaneCommodeCrutchesHospital BedHoyer LiftKnee ScooterMedical ReclinerO2 ConcentratorO2 TankPediatric ScooterPediatric WalkerPediatric WheelchairRaised Toilet SeatRampRollatorShiva EquipmentShower ChairTransport WheelchairWalkerWheelchairOther
Condition of Item(s)*

ExcellentGoodFair
Upload a Photo of the Item(s)*

Cancelof
Additional Comments:
Office Email
example@example.com
Should be Empty: