Rental Reservation Request - Mobility & More

Rental Request Form

Please complete the rental reservation details and submit form below. We will contact you ASAP to confirm your rental reservation. Please feel free to call or email us for more information or if you have any questions regarding your reservation request. Thank you!
Start Date
End Date
Rental Information
Please choose the items below you would like to rent.

Transport Wheelchair - Four Small TiresStandard Size Manual WheelchairHeavy Duty Manual WheelchairTransportable Mobility ScooterStandard or Heavy Duty Mobility Scooter - Does Not Come ApartElectric Standard Wheelchair - Does Not Come ApartTransportable Electric WheelchairPower Lift Chair/ReclinerElectric Hospital BedManual Stair ClimberElectric Patient (Hoyer) LiftSit-To-Stand LiftGeri ChairStandard WalkerRollator WalkerKnee Walker/ScooterFoldable Wheelchair RampScooter Carrier/Lift for VehicleICE Therapy MachinePortable Oxygen Concentrator
Name of person using the rental?*

First NameLast Name
Mobile Phone Number*

Area CodePhone Number
Email Address*
We will email you once rental has been confirmed
Approximate height of user?*
Approximate weight of user?*
Pick-Up or Delivery? (Local delivery charge for most items is $125 and includes pick up ($150 for Hospital Beds & Liftchairs - includes delivery/set-up/pick up)*
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? $200 deodorization charge if evidence of smoke order*
Smoke Free Enviroment?
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.*

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Should be Empty:

Rental Request Form

Rental Information