Client Name *

Please enter the name of the individual using the equipment.

First Name

Last Name

Phone *

Please enter phone number to best reach client or person requesting equipment.

(###)

###

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Address *

Please list address of client. This is only for our records and will remain confidential.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What type of equipment are applying to wait list for? *

We cannot guarantee the time frame you will be wait listed for. Once we have an item available and you are first on the list, we will contact you.

Wheelchair

Walker

Bedside Commode/Toilet Riser

Shower Chair/Bench

Incontinence Supplies

Medical Furniture (Hospital Bed, Lift Chair, etc.)

Specific Miscellaneous Item (listed on our website)

Other (not listed on our website)