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Name*

Our Services*

Email*

Best number to Reach you*

Alternative Number (optional)

Quantity*

Please enter a number greater than or equal to 1.

Rental Start Date

Rental End Date

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Number of Days

Please enter a number greater than or equal to 1.

Additional cost for more than one day

Total

Where are you staying at?*

What is the exact name and the address of the Hotel or the Vacation Rental you will be staying at?*

Residence Address*

Street Address Address Line 2 City ZIP / Postal Code

Is pickup and delivery the same address?*

Yes

No

Height of the person using the equipment?*

Weight of the person using the equipment?*

Does that person know how to operate a mobility scooter?*

Yes

No

Unsure

Does he or she own a mobility scooter?*

Yes

No

Unsure

Do you need a demonstration on how to operate/charge or disassemble your portable scooter to put into a vehicle?*

Yes

No

Please put Free Demonstration. It takes about 15 minutes and may help you and your family feel more secure and safe using the equipment. And we will show you how your portable scooter fit in a car.

How many? (Mobility scooter to rent)*

How did you hear about us?*

Referral Hotel (Optional)

Referral Name

Please provide information if you have it this time.

Requested Date of Delivery*

Requested Time of Delivery*

Requested delivery time is subject for approval and could be adjusted by the driver 30mins either way. For other delivery schedule request, please indicate on Special Request Box provided below.

Requested Date of Pickup*

Requested Time of Pickup*

Requested pick-up time is subject for approval and could be adjusted by the driver 30mins either way. For other pick-up schedule request, please indicate on Special Request Box provided below.

Special Requests

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Credit Card

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