island mobility equipment hire
Please fill in as required,  items marked with a * must be entered or the form will not submit

 

 Contact Information
 First Name*

 

  Last  Name**

 
 Telephone  №

 

  Mobile   №

 
 e-mail*

 

  Repeat e-mail*

 
  Accommodation Information
 (please enter 'unknown' for any information that you are unsure of)
 Resort *           eg; Playa Blanca, Costa  Teguise,  Puerto del Carmen etc

 Hotel/Villa Name   

 Villa No. & Street Name   

  Flight Details
 (please enter 'unknown' for any information that you are unsure of)
 Arrival Date*          Flight  №. Arrival Time:     

 Departure Date*          

Flight  №. Departure Time 

 

  Please tick the items you require, at the bottom of this page is space   

  for you to provide any additional information that you think is relevant.

  Electric Scooters
  Electric Scooter – Luxury       Electric Scooter - Large       Electric Scooter- Midi       Electric Scooter Transportable    
  Electric & Manual Wheelchairs
 

Electric Wheelchair                

 

Lightweight Manual Wheelchair – Adults size   

  Manual Wheelchair – Large     

Lightweight Manual Wheelchair – Childs size    

                                                              Self Propelled Shower  Wheelchair                   

  Hoists
  Electric Hoist    Electric Bath Lift    Pullman Helper             
  Rota stand          Bed Cradle                 Adjustable Back Rest   

  Bathroom Aides
 

Shower Chair - with wheels 

 

Shower WheelChair - Self Propelled 

 

Shower Chair - no wheels

  

Shower/Commode Chair Combo 

 

Electric Bath Lift

  

Static Commode Chair

 

Shower Stool 

 

Bath Board

 

Toilet Support

 

Toilet Seat Riser
 

Toilet Frame - Raised commode

 

 

 

 
  Bedroom Aides
  Electric Bed    Electric Hoist    Adjustable Bed Table  
  Bed Cradle        Rota stand          Adjustable Back Support 
  Back Rest       Bed Rail (pair)     Patient Helper Pole
      Air Mattress   Cot Side   (full bed length)
  Walking Aides
  Rollator 4 wheels   Zimmer Frame   Walking Sticks   Crutches
with basket & seat

  Please enter any additional information you think is helpful.