Power Wheelchair Rental Program

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Base Model:	QUICKIE Q700QUICKIE Q400/500QUICKIE Q300Magic 360Magic V6XcelXperienceXplore
Product Selections:	TiltLiftPower ReclineElevating Leg RestsStandard Sedeo Backrest
Seat Width:	16"18"20"22"
Seat Depth:	16"18"20"22"
Seat Width (Xcel only):	19"20"22"24"26"28"
Seat Depth (Xcel only):	18"20"22"24"
Joystick Location:	Left Hand Right Hand
Cushion:	Jay IonJay UnionJay FusionJay 2Jay 2 DC
Backrest:	Jay 3 Backrest Posterior Shape Jay 3 Backrest Posterior Deep Contour Jay 3 Backrest Posterior Deep Lateral Contour Jay 3 Backrest Laterals
Other Requirements:
Start Date:
End Date:
Client First Name:
Client Last Name:
Client Email:
Client Telephone:

Therapist Name:

Therapist Email:

Dealer Name:
Dealer Company Name:
Dealer Email:
Dealer Telephone:
Who is the primary contact for this quote?:
Delivery Address:
Pick Up:
Disclaimer:	I agree and understand that submitting a request does not guarantee product availability. Product suitability will be determined by Rental agreement /disclaimer

Power Wheelchair Rental Program

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