Power Mobility Rental Form

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DURABLE MEDICAL EQUIPMENT COMPANY

Use tab to navigate through the menu items.

First Name

Last Name

Address

Home Phone

Cell Phone

I want to rent:

Choose your options

Oxygen Holder

JoyStick on Right Side (This option is for Power Wheelchair only)

Joystick on Left Side (This option is for Power Wheelchair only)

Date I want to rent

Date I want to return

We'll send you a confirmation shortly

CONTACT US:

Tel: 619-229-9597 - Fax: 619-229-9594

Monday - Friday: 9:00 AM - 4:00 PM

WE APPRECIATE FOR YOUR REFERRAL

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