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Web Form For Wheel Chair Rentals
             
Customer Full Name:*  
Address:  
Phone Number:*  
Email Address:*  
Customer WT:*   HT:       DOB:
Type of Equipment Needed:   a) Manual Wheelchair      
    b)Power Wheelchair      
    c) Scooter      
    d) Transport Chair      
How Long do you need the wheelchair:*    
Pick Up Date:     Drop Off Date:
           

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Wheelchair Rental Pros. 71st Street, Chicago, IL 60619
Phone: (312) 404-8802 Fax: (773) 602-2171. Email: angelcaremed@yahoo.com

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