2701 West Broadway | Council Bluffs, IA 51501 | Phone: 712.328.2288 | Fax: 712.328.2299 | Toll Free: 888.798.2288
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Questions For Mobilis
Service Questionnaire
request for:
rental equipment
Name
*
First
Last
Address
*
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City
State
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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)
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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?
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Approx. Weight of Individual Using Equipment?
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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
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