Rental Pre-Booking Form

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1Rental Information

2Personal Information

CPAP - Auto

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

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Standard Wheelchair - 16”

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Standard Wheelchair - 18”

<img decoding="async" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px" data-src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/cs-rental_0034_WHEELCHAIR-STANDARD-16_.jpeg" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/cs-rental_0034_WHEELCHAIR-STANDARD-16_.jpeg" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px"/>

Standard Wheelchair - 20”

<img decoding="async" src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/cs-rental_0030_WHEELCHAIR-HD-24_.jpeg" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px"/>

HD Wheelchair - 22”

<img decoding="async" src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/cs-rental_0030_WHEELCHAIR-HD-24_.jpeg" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px"/>

Standard Wheelchair - 24”

Elevating Leg Rests

<img decoding="async" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px" data-src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/SuitcaseRamp1.jpeg" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/SuitcaseRamp1.jpeg" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px"/>

Ramp - Folding 6'

<img decoding="async" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px" data-src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/SuitcaseRamp1.jpeg" class="lazyload" src="data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==" /><noscript><img decoding="async" src="https://www.youcanhomemedical.com/wp-content/uploads/2023/04/SuitcaseRamp1.jpeg" height="90" width="90" style="border:5px solid #168241; padding:3px; margin:5px; border-radius:25px"/>

Ramp - Folding 8'

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Ramp - Folding 10'

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 Date*

Comments or Questions

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(303) 376-7449

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