1
GUEST INFORMATION
First Name
*
Last Name
*
Home Phone
Cell Phone
*
Email
*
2
DELIVERY / PICK-UP INFORMATION
DELIVERY & PICKUP LOCATION
Store Pick-Up & Return- 6127 W Irlo Bronson Memorial Hwy, Kissimmee, FL 34747
Villa, Timeshare, Vacation Home or Other Location
Are You Staying At Multiple Locations?
Pickup Location Is Different From Delivery Location.
Delivery Date & Time
Rental Start Date
*
Please Select Time Block for Delivery
Return Date
Rental Return Date
*
All rentals that do not require a meet & greet are due back at 11am on day of return
3
RENTAL ITEMS
Rental Items
Select Equipment
GO-GO Sport 3 Wheel
GO-GO Sport 4 Wheel
Victory 3 Wheel
Victory 4 Wheel
Wheelchair - 16 Inch, Childs
Wheelchair - 20 Inch, Adult
Wheelchair - 24 Inch, Bariatric
Transport Chair - 19 Inch
Rollator - Adult
3 Wheel Rollator - Adult
Rollator - Bariatric
Knee Walker
Frame Walker
Recliner
Power Lift Chair
Stroller - Single - City Mini
Stroller - Double - City Mini
Stroller - Double - Stand & Ride
Crib - Full Size
Pack N Play
Highchair
Exersaucer
Car Seat
Bed Rails
Swing & Rocker
Baby Gate
Shower Chair
Microwave
Refrigerator
Rollaway Bed
Special Notes
Remove Rental Item
Add Rental Item
4
HOW DID YOU HEAR ABOUT US.
How did you hear about us?
Repeat Guest
Internet
Internet - Google Ads
Hotel/Timeshare/Villa
Guest Service Agent
Other
5
RECEIPT
Equipment
Price
I confirm that I have read and agree to the
Terms & Conditions
*