Knee Scooter Order Form

*Note: All fields marked with an asterisk (*) are required.
*Contact Email*First NameLast Name*Phone NumberDelivery Street AddressDelivery Street Address 2Delivery CityDelivery StateDelivery Zip*Rent or PurchaseRental Options

 Color option subject to availability*

**Color Options

 How would you like to receive your knee scooter?

Delivery Option

What day would you like to have your scooter available?

*Delivery Date

Knee Scooter Damage Report

*Note: All fields marked with an asterisk (*) are required.
First and Last NameSerial #Report Date
Form Date
*Description of DamagePicture Upload

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ProCare Medical Equipment
195 S. Adkins Way,  Suite 107, Meridian, ID 83642
Toll Free: 866.633.5755  |  Fax: 208.322.8033