Wheelchair Hire

Please Note: Fields marked with a * are compulsory.

Title

*Full Name

*E-mail Address

*Phone Number

Alternative Phone Number

*Address

Maximum number of characters: 250

Address Line 2

Maximum number of characters: 250

*City

Maximum number of characters: 250

*County/State

*Postcode

*Do you require delivery and collection service

Yes No

Delivery address if different from booking address

Maximum number of characters: 500

*Delivery Telephone

*Delivery Date

*Return Date

*Wheelchair type required

*Elevated Leg Rests

Comments, questions, or other information

Maximum number of characters: 500

*I declare that I can claim VAT Exemption

*The wheelchair user weight must not exceed 114kgs

I Agree

*I accept UK Wheelchairs Terms

I Agree

* Required Fields