Medical Equipment Loan Request Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastType of Equipment NeededCaneWalkerShower chairBed RailCrutchesWheelchairCommodeWalker trayGait beltToilet raiserOtherIf requesting a walker, what type are you looking for (standard, 2-wheeled, 4-wheeled, etc)?AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *If sharing your cell phone and by submitting this form, you agree to receive SMS from Eastside Senior Services. Carrier and Data rates may apply. Message frequency may vary Reply STOP at any time to end messaging or Reply Help for more information or you can say any information entered on this page will not be used to initiate SMSEmailNotesMessageSubmit
