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Equipment Rental Request Form

HomeCatalogEquipment Rental Request Form

Medical Equipment Rentals Made Easy

Need short-term access to mobility or home medical equipment? We offer convenient rental options for wheelchairs, hospital beds, scooters, and more. Whether you're recovering from surgery, traveling, or testing a product before purchasing, our rental program provides flexible, affordable solutions.

Fill out the form below to request a rental, and our team will be in touch with you to help you find the right equipment for your needs.

  • Personal Information

    * - Indicates required field

  • Rental Information

    • Dates

  • Rental Terms and Conditions:

    1. Any technical issue or malfunction of the rental equipment has to be reported to Empower Mobility by the renter or his/her representative ASAP.

    2. The renter is responsible for any damage or loss of the rental equipment and gives the right to Empower Mobility to charge the cost of repair or the whole retail price of the equipment in case of loss.

    3. The rental equipment has to be used in the proper way by the renter only. The renter will not allow the equipment to be used or played with by the others, especially children.

    4. The rental equipment has to be kept in a dry and clean place when not in use.

    5. The rental mobility products should not be used under the rain, snow or on icy or slippery surfaces.

    6. The client is responsible for any injury or damage caused by negligence, misuse, accident or abuse of the equipment.

    7. The renter hereby gives authorization to charge the on-file credit card for any due rental charge, repair cost of damaged equipment or the total cost for lost equipment.

    8. The late payment interest charge will be 2% per month.