Wheelchair and Scooter rentals for home and residential useScootaround Residential Delivery Request Form

For easy home delivery of all types of mobility equipment, please complete this request form. Once we receive your rental request, a Scootaround operator will forward you a detailed quote online directly to your e-mail Inbox!

• Fields marked in Bold are required.
• This is not a booking form -- all rentals must be confirmed.

Personal Information
First Name
Last Name
Street Address
Country State / Province
Other Country
ZIP / Postal
Equipment User's Height
Equipment User's Weight
Contact Information
Please provide both your telephone and e-mail address so we may respond in the quickest method possible:
Area Code + Phone
Area Code + Work Phone
Email Address
Rental Information
Equipment Type
Equipment types shown here are examples only and may vary based on your location.
Destination City
Destination Address
Date Needed From
Date Needed To
Will someone be at the door and available to receive the rental equipment when our driver arrives? (please enter Yes or No). If No, please enter the details in the Special Needs section below.
Special Needs or Concerns
This is not a booking form.
All rentals must be confirmed!