Rental Application

2701 West Broadway | Council Bluffs, IA 51501 | Phone: 712.328.2288 | Fax: 712.328.2299 | Toll Free: 888.798.2288

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- Service Questionnaire

request for: rental equipment

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alternate Phone Number *

Email Address *

What product(s) are you interested in? *

Standard Wheelchair Scooter Power Wheelchair Transport Chair Knee Walker Portable Concentrator Modular Ramp Foldable Ramp Patient Lift (Electric) Patient Lift (Manual) Hospital Bed (Full Electric w 1/2 Rails)

(Check "ALL" that apply)

Additional Comments (List anything that will help educate us on your request) *

When finished, click on the submit button below. We will contact you soon from the information we learned from this survey. Thanks for your interest.

Approx. Height of Individual Using Equipment? *

Approx. Weight of Individual Using Equipment? *

What date do you need your rental equipment by? *

$60 Delivery & $60 Pickup? (Pick one) *

Delivery & Pick-Up by Mobilis Staff Requested Item Will be Picked Up & Dropped Off By Customer

Note: Delivery/Pick-Up Fees will be applied. Fees will be determined by the type of product requested and location of delivery/pick-up.

(If Delivery Requested) Delivery Address *