Citizens Pharmacy Medical Equipment Rental Agreement
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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
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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
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Debit or Credit Card
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