Complete the Form Fields Below

Please complete this form with the equipment-user’s information. If you are requesting the device for yourself, provide your information as both the Contact and as the Consumer.

Once these form fields are complete and submitted, the item is removed from our online inventory, and a page will display with a unique request ID number. Make note of this request ID number in case you need to call us about your request. 

Required fields are marked with an *.

Questions?

Contact our office toll free at 800-261-9841.


 

Item Requested: KNEE SCOOTER 7X13
Consumer
Address

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Are you a Veteran?
To select multiple disabilities, hold CTRL (PC) or ⌘ (Mac).
in
lb

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Low income
Someone receiving public assistance or benefits, such as receipt of SSI, Medicaid, TANF, SNAP, Section 8/Housing Vouchers or residing in subsidized housing, and similar benefits.
Limited English
Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand the English language.