Rental Pre-Booking Form

Home » Rental Pre-Booking Form

"*" indicates required fields

Please note that your information is saved on our website as you enter it.

CPAP - Auto

Lumex Stand Assist

Home Stationary Oxygen - 5L

Home Stationary Oxygen - 10L

Portable Oxygen - Pulse/Continuous

Hospital Bed - Full Electric

Low Airloss Mattress and Pump

Trapeze Bar

Overbed Table

Patient Lift - Standard

Patient Lift - Power

Sit to Stand Lift

Ice Therapy Machine

Knee Walker - Standard

Knee Walker - HD

Standard Wheelchair - 16”

Standard Wheelchair - 18”

Standard Wheelchair - 20”

HD Wheelchair - 22”

Standard Wheelchair - 24”

Elevating Leg Rests

Ramp - Folding 6'

Ramp - Folding 8'

Transport Chair - Standard

Transport Chair - HD

Rollator 4-Wheel - Standard

Rollator 4-Wheel - HD

Lift Chair - Standard

Lift Chair - Premium

Power Scooter - Standard

Power Scooter - HD

Power Wheelchair - Standard

Stairlift

Rental Equipment Needed*

How will you receive your rental?*

Closest Store Location*

Rental Period*

Preferred Pickup / Delivery Date*

Comments or Questions

Name*

First Last

Email*

Phone*

Your Height*

Your Weight*

No Solicitation Please

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Call Us

(303) 376-7449

Visit Us

4 Retail Locations