Rental Pre-Booking Form

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1Rental Information

2Personal Information

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*

Delivery Address

Street Address Address Line 2 City State ZIP Code

Preferred Pickup / Delivery Date*

Comments or Questions

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