Booking request form

    Product : XL manual wheelchair

    Your first name (must fill)

    Your surname (must fill)

    Your phone number (must fill)

    Your weight (must fill)
    Kgs

    Your email address (must fill)

    Your address: (must fill)



    Required hire date (must fill)

    Return date (must fill)

    Equipment delivery address :





    If you want to return to another address, please indicate it below





    Your message