MIA – POWER WHEELCHIAR ONLINE BOOKING – relinquomedicalstay.com

MIAMI POWER WHEELCHAIR

PORTABLE LIGHT LUX POWER WHEELCHAIR ONLINE BOOKING - MIAMI, FL

Deliveries only in Miami, FL and surrounding areas

Equipment Rental

Portable Light Lux Power Wheelchair

Daily Rate $48 - *(Minimum Rate $145- includes 3 days)

*If rental is needed for 1-2 days, the minimum rate applies.

Delivery Date

Pick up Date

CONTACT INFORMATION

Contact Name

Contact Last Name

Patient / User ( Same as Contact )*

YES

Patient Name

Patient Last Name

Estimated Weight (LBS)

Estimated Height (FT/IN)

Primary Phone / Mobile

Alternating Phone / Mobile

DELIVERY AND PICKUP ADDRESS

*The equipment must be picked up at the same location it was delivered to. If the location is changed by the customer’s request, a rate change or special charges may apply.

Address Type

Delivery Address

City

State

Zip Code

Gate Code # (Optional)

The delivery is to a second floor or higher without an elevator or the front entrance has more than three steps without an access ramp. *If it's a 'yes,' charges may apply. *

YES

Delivery Instructions / Comments and/or Special Request *

BILLING INFORMATION

First Name

Last Name

Company/Organization Name (optional)

BILLING ADDRESS

Is the billing address same as the delivery?

YES

NO (Fill the billing address below)*

Country

Address

Apt/Room/Suite # (optional)

City

State

Zip Code

I have read and agree to the Terms and Conditions and Privacy Policy

I consent to have this website store my submitted information so they can respond to my inquiry. Data Compliance

IMPORTANT NOTICE

A representative will contact you shortly to confirm the order. You won't be charged for your booking until we have thoroughly discussed and confirmed with you all the requirements and rates specified in the order.

After confirmation, a representative will send you a digital contract by email for you to review and sign. Once you have given your approval, you will be charged using our secure Point of Sale (POS) system.