REFERAL INFORMATION

Prepared By:

Name:

Phone:

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CUSTOMER INFORMATION

Name: *Required

Home Phone:

Height: Weight:

Cell Phone:

Home Address:

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EQUIPMENT INFORMATION

Cruise Ship:

Date Departing:

Date Returning:


	** Includes Delivery Fee
EQUIPMENT	3 Night Cruise	4 Night Cruise	7 Night Cruise

Standard Wheelchair	$70.00	$80.00	$110.00
Std. Wheelchair w/ Elevated Leg Rests	$85.00	$100.00	$145.00
Wide Wheelchair	$85.00	$100.00	$145.00
Electric Wheelchair (Check Availability)	$130.00	$160.00	$250.00
Scooter	$130.00	$160.00	$250.00
Hoyer Lift	$70.00	$80.00	$110.00
Hospital Bed	$120.00	$135.00	$180.00
O2 Concentrator	$100.00	$120.00	$180.00
Conserving Device (Check Availability) **	$15.00	$20.00	$35.00
Portable Oxygen Set-up	$47.50	$47.50	$47.50
E-Tank Refills each **	$10.00	$10.00	$10.00
M-6 Tank Refills each **	$5.00	$5.00	$5.00
3-N-1 Commode	$47.50	$47.50	$47.50
Nebulizer	$45.00	$45.00	$45.00
Shower Chair (On Wheels)	$50.00	$50.00	$50.00
Walker	$50.00	$50.00	$50.00

Delivery to Orlando Airport’s / Resorts (1-way)”. The fee across the board is $125.

** Price does not include delivery/pick-up charge as item is expected to be used with other equipment being rented. We have many other items for sale and/or rent available. Please contact us for more information.

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METHOD OF PAYMENT:

We accept: • VISA • MasterCard • DISCOVER • AMEX

You will be contacted for specific rental and payment information.

EQUIPMENT SAFETY RULES:

Please print, fill out, and fax or mail the Equipment Safety Rules before hitting submit.
Be sure to include the address and fax:

VGM Forbin
P.O. Box 2817
Waterloo, Iowa 50704
FAX: 877.389.8420