Nashville / Murfreesboro VA Medical Centers
Medical Equipment Rental Request Form
Name of Requestor:
*
First Name
Last Name
Email Address:
example@example.com
Phone Number:
-
Area Code
Phone Number
Location
Nashville Campus VA Medical Center, 1310 24th Ave South, Nashville, TN 37212
Alvin C. York VA Medical Center, 3400 Lebanon Pike, Murfreesboro, TN 37129
Patient Name or Room Number:
Request Date:
-
Month
-
Day
Year
Date
Please Select One:
New Order Request
Maintenance/Swap Request
Pick-Up Request
Item Request:
Freedom Wave II 36" 500LB Weight Capacity
Freedom Wave II XMS 1000LB Weight Capacity
Freedom 500 - Low Bed w/ Battery Backup
Versatech 1100 - Bariatric 1100LB - 8" Low Bed w/Battery Backup
Defined Perimeter Foam Mattress 35"
Freedom Wave 36" Immersion LAL/Pulsate
Freedom Comfort Turn Bariatric 1000LBS
Freedom Comfort IV Standard
Freedom Comfort IV XMS Bariatric
Medical Trapeze Bar
T.H.E. Bariatric 1000 LB Lift
Bedside Recliner
Shower Commode 750 LB
Walker 1000 LB
WINCO 1000 LB Rehab Chair
Comments:
Submit Request
Should be Empty: