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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Quote only
New Customer 
Full Name *
Company Name (Optional)
Email *
Mobile phone *
Home address
Where are you staying
Clear selection
Hotel name and guest Name
Delivery Address
User Full Name
Rental duration
Type of Equipment
Type of mobility scooter
Weight
Height
Has the user used a scooter before
Clear selection
Equipment delivery time
Time
:
Rental starting date
MM
/
DD
/
YYYY
Return end date
MM
/
DD
/
YYYY
Pickup time
Time
:
Where are you using the Mobility scooter 
Clear selection
Additional Comments and questions
Submit
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