Rental Reservation Request - Mobility & More

Rental Reservation 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.
Our showroom hours are Monday - Friday from 10AM-5PM. Thank you!
Start Date
End Date
Transport Wheelchair - Four Small TiresStandard Size Manual WheelchairHeavy Duty Manual WheelchairTransportable Mobility ScooterStandard or Heavy Duty Mobility Scooter - Does Not Come ApartTransportable Electric WheelchairStandard Electric Wheelchair - Does Not Come ApartPower Lift Chair/ReclinerElectric Hospital BedManual Stair ClimberElectric Patient (Hoyer) LiftElectric Sit-To-Stand LiftGeri ChairStandard WalkerRollator WalkerKnee Walker/ScooterSeated Knee Walker/ScooterFoldable Wheelchair RampScooter Carrier/Lift for VehicleICE Therapy MachinePortable Oxygen Concentrator
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 from Charlotte, NC locationPick up from Indian Land, SC locationLocal delivery of Liftchair or Hospital Bed ($150 - includes pick up)Local delivery of standard item(s) - scooters, wheelchairs, lifts, etc. ($125 - includes pick up)
Delivery Address (credit card mailing address if item not being delivered)*

Street Address

Street Address Line 2

CityState

Zip Code
First FloorSecond FloorThird FloorOther
1-3 Steps3-5 Steps5 Or More StepsN/A
YES Smoke Free EnvironmentNO ($200 deodorization charge if evidence of smoke odor)N/A
Half Rails (Most Popular)Full RailsNo Rails
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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Rental Reservation Request Form