Manual Plus Wheelchair Reservation: Chair

Reserve a
Manual Plus Wheelchair

Please use the form below to reserve a Manual Plus Wheelchair. You will be emailed a confirmation of the reservation and a representative will contact you shortly.

Note: All online reservations must be made at least 48 hours in advance of the requested rental date. If you need to request delivery within the next 48 hours, please call our toll-free line at 866-866-3434 to book your rental.

Customer
First Name:
Last Name:
Address:
City:
State/Province:
Zip/Postal:
Country:
Phone:
Email:
Rider's Weight:
Mode of Transportation:

Billing
First Name:
Last Name:
Address:
City:
State/Province:
Zip/Postal:
Country:

Reservation
Product:
Date:
Number of Days:
Delivery Time:
Location/Resort:
Comments:

Payment
Total: $52.00
Type:
Number:
Expiration:
/
Code (CVV):
Required

 

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