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Rental Form
Please note: We’ll send you the invoice to your email and a text message, If you’re not interested just reply Not Interested.
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* Required
Quote only
No
Yes
New Customer
Yes
No
Full Name
*
Your answer
Company Name (Optional)
Your answer
Email
*
Your answer
Mobile phone
*
Your answer
Home address
Your answer
Where are you staying
Hotel
Residence
Airbnb
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Hotel name and guest Name
Your answer
Delivery Address
Your answer
User Full Name
Your answer
Rental duration
Choose
1 day
2-3 days
1 week
1 month
6 weeks
Type of Equipment
Full Mobility scooter **** Doesn't dissemble***1-3 days rental $159.00 4-7 days $212.00 delivery charges may apply depending on location and stat deliveries.
Transportable Scooter ***Breaks down in 3 pieces
Regular Manual wheelchair ****35lb*** 1-7 days rental $106.00 delivery charges may apply depending on location and stat deliveries. .
transport wheelchair ***weights 25lb***1-7 days rental $106.00 delivery charges may apply depending on location and stat deliveries.
Electric wheelchair
Knee scooter 1 day -4 weeks rental $159.00
Ramp
Rollator/walker
Other:
Type of mobility scooter
Choose
3 wheels
4 wheels
Weight
Your answer
Height
Your answer
Has the user used a scooter before
Yes
No
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Equipment delivery time
Time
:
AM
PM
Rental starting date
MM
/
DD
/
YYYY
Return end date
MM
/
DD
/
YYYY
Pickup time
Time
:
AM
PM
Where are you using the Mobility scooter
National Mall only
Museum only
Zoo
Hotel Conference
Arlington National Cemetery
Mount Vernon
All the above
Other:
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Additional Comments and questions
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