Rental Pick Up Phone Name * Company Name * Phone * Email * Your Representative * Dennis Griffith, President Brandon Fornachon, Director of Operations Penny Kampeter, Regional Sales Manager Josh Carrithers, Regional Sales Manager Colton Bewley, Regional Sales Manager Christopher Varcoe, Regional Sales Manager Lori Riti, PT, CWS NOTE This is a rental PICK UP form. If you have rental items you need picked up, this is the form you should fill out. If you are looking for a quote on renting items, please fill out this form instead. Please enter the quantity for each product you need picked up. Please note any changes to patient names and/or room numbers in the comment section at the bottom of this form. A weekly update works best. BEDS Medacure Lincoln Expandable Bed Drive P903 Bed Drive P703 Bed Drive P503 Invacare Drive Overbed Tables LIFTS / TRAPEZE Slings – Solid / Mesh / Divided Leg (Small – XXL) Pride Lift Chairs Trapeze 1000lb Trapeze 600lb Trapeze 500lb Trapeze 450lb Trapeze 250lb Drive Sit to Stand Lift Tollos Titan 1000lb Lift Drive Lift 600lb Invacare Lift 450lb NEGATIVE PRESSURE WOUND THERAPY NPWT Pump RESPIRATORY / SLEEP THERAPY / MOTION CPM Machine CPAP Auto BiPAP Auto Suction Machine Compressor 50 PSI Pulse Oximeter Nebulizer iGO2 Portable Oxygen Concentrator * Concentrator 10 Liter Concentrator 5 Liter w/ OPI Edan M3 Vital Signs Monitor SUPPORT SURFACES / FALL PREVENTION EQUIPMENT Balanced Aire Self Adjusting, Non-Powered Competitor Mattress Bariatric 42in LAL Mattress Bariatric 48in LAL Mattress Bariatric Mattress Cover With Bolsters Standard Mattress Cover With Bolsters Lateral Rotation Mattress Low Air Loss 84in Mattress Low Air Loss Mattress Beveled Edge Fall Mats ROHO PRODIGY Mattress Overlay System Scoop Mattress Foam with Perimeter Edges Standard 42in Mattress Standard 48in Mattress Standard 80in Mattress Standard 84in Mattress WHEELCHAIRS / CUSHIONS Broda Chair – Pedal Rocker Broda Chair – 18-20″ Broda Chair – 22-24″ Broda Chair – 26″ Hi-Back 18in-20in Hi-Back 22in Geri Chair – 18″ Geri Chair – 19″ Geri Chair – 25″ Bariatric Star Cushions Bariatric Wheelchair Gel Cushions - 22" Bariatric Wheelchair Gel Cushions - 24" Bariatric Wheelchair Gel Cushions - 26" Bariatric Wheelchair Gel Cushions - 28" Bariatric Wheelchair Gel Cushions - 30" Wheelchair Cushions Foam - 16, 18, 20 in Wheelchair Cushions Gel - 16, 18, 20 in Bariatric Wheelchair 22in Bariatric Wheelchair 24in Bariatric Wheelchair 26in Bariatric Wheelchair 28in Bariatric Wheelchair 30in Wheelchair 16in-20in with ELR Wheelchair 16in-20in with Swing Away Leg Rest Comment CAPTCHA
