Rental Form

Name:

Equipment Type Equipment TypeStandard Scooter (Up to 300 lbs)Heavy Duty Scooter (Up to 400 lbs)Extra Heavy Duty Scooter (Up to 500 lbs)Transportable Scooter (Up to 300 lbs)Push Wheelchair (Up to 250 lbs)Heavy Duty Push Wheelchair (Up to 450 lbs)Standard Eletric Powerchair (Up to 300 lbs)Heavy Duty Electric Powerchair (Up to 350 lbs)Reclining Lift Chair (Up to 300 lbs)Knee Walker (Up to 300 lbs)Rollator (Up to 300 lbs)Single Stroller (Up to 65 lbs)Double Stroller (Up to 100 lbs)

Start Date

End Date

Rental Delivery Location

Rental Pickup Location

Phone Number

Email Address

User Height & Weight

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