MANUAL WHEELCHAIR & TRANSPORT CHAIRS

Name on Reservation*

First NameLast Name

Patient name if different than reservation name:

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Patient Height*

Patient Weight*

Preferred Pick Up Date*

MonthDayYearHourMinutesAM/PM Option

Preferred Drop Off Date*

MonthDayYearHourMinutesAM/PM Option

To help us determine if a transport chair or full size chair is better.

	Patient will self propel	Caregiver will push the patient
Yes

Pricing on Standard Full Size Wheelchair or Transport Chair with Footrests - 250 lb weight capacity

Weekly (1 to 7 days) $50(2) Weeks $80Monthly $100

Pricing on Heavy Duty Transport Chair with Footrests. 400 lb weight capacity

Weekly (1 to 7 days) $85(2) Weeks $150Monthly $200

Pricing on Heavy Duty Wheelchair with Footrests. 350 lb weight capacity

Weekly (1 to 7 days) $85(2) Weeks $150Monthly $200

Pricing on Extra Heavy Duty Wheelchair with Footrests. 450 lb weight capacity

Weekly (1 to 7 days) $100(2) Weeks $175Monthly $225

Pricing on Elevating Leg Rests - each

Weekly $15 leftWeekly $15 rightMonthly $15 leftMonthly $15 right

I wil pick up and drop off the wheelchair at LTC Wheelchairs

Yes

I would like a price quote on renting one of the following items:

Tilt in Space ChairHigh Back Reclining Wheelchair4-Wheeled Walker6-ft Suit Case Ramp

Message to LTC Wheelchairs staff:

Enter the message as it's shown*