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Rental Request Form

Fields with an Asterisk (*) Are Required

Equipment Requested

First name*

Last name*

Requested Date - Subject to Availability

Patient Sex

Patient Weight*

Patient Height

Email*

Preferred Contact Method(s)

Delivery Phone #

Billing Phone #

Email

Pickup Or Delivery*

Pickup From Our Tampa Location

Pickup From Our Largo Location

Delivery

Delivery Phone*

Delivery Address 1*

Delivery Address 2

Delivery City *

Delivery State*

Delivery Zip*

Billing Address is the Same as the Delivery Address

Billing Phone #

Billing First Name

Billing Last Name

Billing Address 1

Billing Address 2

Billing City

Billing State

Billing Zip

Please Upload Your Identification

Please provide any additional information (Optional)

Store Locations and Contact Information

Health Aid Medical - Tampa

4502 N Armenia Ave, Tampa, FL 33603

Phone: (813) 879-7552

Toll Free: (800) 835-8513

Fax: (813) 876-2621

Email: sales@healthaidcompany.com

Hours: M - F 9am - 5pm Saturday 9am - 12pm

Health Aid Medical - Largo

1156 Jasper Street, Largo, FL 33770

Phone: (727) 586-2995

Toll Free: (800) 831-9099

Fax: (727) 588-0899

Email: largosales@healthaidcompany.com

Hours: M - F 9am - 5pm

Health Aid Company,INC.

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