Seated Support Chair Rental - Weekly with Free Ground Shipping | Vitrectomy Recovery

Rental Periods *

Select rental period...

Patient's Name *

Surgery Date is First Rental Use Day | Equipment will deliver 1-2 days before this *

Insurance Forms to File for Reimbursement *

-- Please Select --Yes, E0636 MutliPositional Patient Support System No, thank you. I am not filing for insurance reimbursement

Physician Name / Practice Name / Address

Physician Phone

Damage Protection: Shipping Insurance, Covers damage over the $100 insurance included by FedEx, Protect Your Security Deposit from Possible Damage to Rentals During Shipping *

-- Please Select --Yes, please add insurance +$5.99No thank you, I will pay for carrier damages if damages occur on the return shipment

Is someone helping you with this order?

-- Please Select --No Allison John

How did you find us?

-- Please Select --Brochure from my Doctor Google Referral from a friend or colleague I am already a customer

Fuel Surcharge + Carrier Oversize Box Handling *

-- Please Select --Deliver to Residence, Indirect Signature Required + Oversize Box + Fuel Surcharge +$46.00Deliver to Business, Adult Signature Required + Oversize Box + Fuel Surcharge +$46.00Customer Pickup, FedEx Return +$23.00Customer Pickup and Return

* Required Fields