Scooter and Wheelchair Rental - Complaint Form

Complaint Form

Primary Information:

First Name:*

Middle Initial:

Last Name:*

Phone:*

Email Address:*

Confirmation#:

Complaint:

CAPTCHA Code:

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Hotel
Residential

Delivery location

State

Hotel

Rental date

Date

Time

Return Date

Date

Time

Weight

Height (')

Height ('')

Equipment

Cancellation Policy

Equipment Protection Plan