Reservation Request Form

Please complete this form to initiate your wheelchair or scooter reservation online.Once we receive this form, a representative will immediately contact you for your rates and final confirmation with a credit card. What is a Final Confirmation? Final Confirmation is to ensure that we have the right equipment for and to thoroughly check our inventory for the appropriate product. We can either contact you by phone or email, this depends on your preferred method of contact.

Or you can simply call us at 202-387-1960 or (866) 474-4356, reservation takes less than 10 minutes to complete over the phone (our preferred method)

Primary Information:
First Name:	*
Last Name:	*
Street Address:	*
City:	*
State:	Please Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Wahsington, DC Washington West Virginia Wisconsin Wyoming *
Zip Code:	*
Contact Information:
Please provide preferred contact method Telephone Email
Phone:	*
Email Address:	*
Rental Section:
Please select Equipment Type you are interested in reserving Scooter         Power Wheelchair      Manual Wheelchair                           *
Destination:	Airport Hotel Convention Residence Other
Destination Name:	*
Destination Address:	*
User Height:	*
User Weight:	*
Rental Date (From):	*
Rental Date (To):	*
Other Information concerning your reservation:
How did you hear about our company?