Medical Equipment Lending Form | Valley Charities Inc

Thank you for contacting Valley Charities Durable Medical Equipment Loan Program.

Your request will be reviewed, and we contact you with the information you provide below. You will be advised when your requested Durable Medical Equipment can be made available for pick up.

Date for Equipment Pick Up *

Responsible Person's Name *

First

Last

Phone Number *

Email Address *

Person Using Equipment *

First

Last

Is User: *

Male
Female

Approximate Height: *

Weight: *

User's MatSu Address *

City *

State

Zip Code *

Equipment Type

Quantity

Equipment Type

Quantity

Equipment Type

Quantity

Equipment Type

Quantity

Equipment Type

Quantity

Equipment Type

Quantity

Email