Rental Form
* Required
Quote only
No
Yes
Full Name
*
Your answer
Company Name if you want us to bill the employer
Your answer
Email
*
Your answer
Mobil phone
*
Your answer
Home address
*
Your answer
Where are you staying
Hotel
Airbnb
Residence
Hotel name and guest Name
Your answer
Delivery address
Your answer
Rental duration
Choose
1 day
2-3 days
1 week
1 month
6 weeks
Type of Equipment
Choose
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 Mobility scooter **** Breakdown in 3 pieces***1-3 days rental $159.00 4-7 days $212.00 delivery charges may apply depending on location and stat deliveries.
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 1-7 days rental $106.00 1 month rental $159. delivery charges may apply depending on location and stat deliveries.
Ramp
Rollator/walker
Type of mobility scooter
Choose
3 wheels
4 wheels
Weight
Your answer
Height
Your answer
Have the user used a scooter before
Yes
No
Equipment delivery time
Time
:
AM
PM
Rental starting date
MM
/
DD
/
YYYY
Return end date
MM
/
DD
/
YYYY
Pickup time
Time
:
AM
PM
Additional Comments and questions
Your answer
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