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Rental Equipment Form

CUSTOMER INFORMATION

* Denotes a required field

* Name:

* Home Phone:

Height: ft in Weight:

Cell Phone:

* Street:

* City: * State: * Zip Code:

* E-mail Address:

* Date Needed: (mm/dd/yyyy)

* Date Returning: (mm/dd/yyyy)

	EQUIPMENT
	Standard Wheelchair
	Std. Wheelchair w/ Elevated Leg Rests
	Wide Wheelchair
	Electric Wheelchair
	Scooter
	Hoyer Lift
	Hospital Bed
	O2 Concentrator
	Conserving Device
	Portable Oxygen Set-up
	E-Tank Refills each
	M-6 Tank Refills each
	3-N-1 Commode
	Nebulizer
	Shower Chair (On Wheels)
	Walker
	Other
If you checked "Other" Please Specify:

Comments or Special Instructions:

We accept: • VISA • MasterCard • DISCOVER • AMEX

You will be contacted for specific rental and payment information.

Desert Medical Equipment
3555 W. Reno Avenue, Suite F
Las Vegas, NV 89118
Phone: (702) 876-9171
Toll Free: (866) 711-9171
Fax: (702) 876-9083