Rental Reservation Request - Mobility & More

Rental Reservation Request Form

704-821-7777 | www.ShopMobility.com
Please complete the rental reservation details and submit form below. We will contact you ASAP to confirm your rental reservation has been approved and the pricing details. Please feel free to call or email us if you have any questions before booking your reservation request. Our showroom hours are Monday - Friday from 9:30 AM-5PM. Thank you!
Start Date
End Date
Please choose the item(s) below you would like to rent.
Name of person using the rental?

First NameLast Name
Mobile Phone Number
Format: (000) 000-0000.
Email Address
We will email you once rental has been confirmed
Approximate height of user?
Approximate weight of user?
Pick-Up or Delivery?
Delivery Address (credit card mailing address if item not being delivered)

Street Address

Street Address Line 2

CityState

Zip Code
First, Second, Third Floor Delivery?
How many steps to enter the residence?
If a liftchair or hospital bed is being rented, will it be in a Smoke Free Environment?
If renting a hospital bed, what type of side rails do you want?
Additional Requests or Information you would like for us to know about your rental reservation?
Name of consultant helping you?
How did you hear about us?
Signature - By singing below you agree to the terms & conditions / rental agreement.
Should be Empty:

Rental Reservation Request Form