Citizens Pharmacy Medical Equipment Rental Agreement
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My Products
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Wheelchair 2 Month Rental
Available in 16-, 18- and 20-inch sizes. All chairs include foot rests. Weighs 32-35lbs. 300 lbs. max capacity
$
120.00
Knee Scooter 2 Month Rental
Available in black and pink. One handed braking systemIncludes wire basketWeighs 27 lbs.300 lbs. max capacity
$
120.00
Rollator Walker Monthly Rental
$
90.00
Quantity
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ADMINISTRATION
For Pharmacy Use Only
Serial Number
Person completing this rental form
Please Select
Ashley Brown
Jasmine Costin
Samir Shah
Taylor Bourdage
Artisha Davis
Jessica Jahuey
Jacqueline Onoz
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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