EQUIPMENT RESERVATION FORM Question Title * 1. Have you rented this equipment before? Yes No Question Title * 2. Who is renting the equipment? Name * Company Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country Email Address * Phone Number * Question Title * 3. Alternate Phone Question Title * 4. Date of Birth Question Title * 5. Patients Height Question Title * 6. Patients Weight Question Title * 7. Equipment Requested:(BWC's are delivered to the beach access location the patient will be using. Transport chairs are offered at a discount for use between the unit and beach access when paired with bwc rentals. Question Title * 8. Do you have a specific purpose for this rental? Question Title * 9. Other Equipment Requested: Question Title * 10. Rental Start Date/Time requested: Date / Time Date Time AM/PM - AM PM Question Title * 11. Rental End Date/Time requested: Date / Time Date Time AM/PM - AM PM Question Title * 12. Name of Resort or Hotel or Vacation Company Question Title * 13. Street address of Resort or Hotel or Vacation Company Question Title * 14. Exact Delivery Address for Equipment: Question Title * 15. Name of person the room reservation is under: Question Title * 16. Check in date: Date / Time Date Question Title * 17. Check out date: Date / Time Date Question Title * 18. Can we leave the equipment at the front desk? Yes No Question Title * 19. Is the front desk on the same property as the unit? Yes No Question Title * 20. What floor is the unit on? First Second Third Higher than third Question Title * 21. Are there stairs or an elevator? Yes No Question Title * 22. Is there a code for the gate or door you can provide for access? Yes No Question Title * 23. Please provide any applicable codes: Question Title * 24. Terms of service:Completion of this form does not guarantee availability.Please note that times will be treated as requests. We cannot make special time accommodations for deliveries or pickups on Saturdays. Any special requests will need to be made between you and your destination. If you must have a piece of equipment upon arrival, you will need to get permission from your destination and provide us with the details. We do have a cancellation policy available at http://www.burkespharmacy.com/dme-#rentalsOnce a delivery is made we do not offer refunds of any amount.People renting a "Beach Wheelchair" should be aware these chairs have a seat height of 31" from the ground. We only delivery BWC's to the beach access that will be used as the "BWC" is not for use on hard or rocky surfaces.Choosing yes below acknowledges and agrees to all of the above statements and conditions. Yes No Question Title * 25. Please provide any comments, requests or questions: Question Title * 26. Please type your full name to serve as a signature that the above information is true and accurate. Submit
