Mobility Booking Form - www.fuertetrikes.com
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Mobility Booking Form
Name:*
E-mail:*
Telephone Number*
Arrival Date*
Departure Date*
Address of Holiday Home*
Type of Mobility*
-
Mobility Scooter €15 per day €90 per week
Wheelchair €10 per day €40 per week
Electric Wheelchair €15 per day €90 per week
Crutches €5 per day €20 per week
Walker €5 per day €20 per week
Size of Mobility Scooter
-
Small
Medium
Large
Special Requirements
Check word:
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