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Spain: +34 606 175 871 / UK: +44 7444487890
Booking Form
Please fill in the details below and we will get back to you as soon as possible. Fields marked
*
are compulsory.
Name
*
Mobile Number
Email Address
*
Accommodation Address
*
Resort Area
*
Costa Teguise
Matagorda
Puerto del Carmen
Playa Blanca
Other
Duration of Hire (days)
*
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31+
Start Date (DD/MM/YYYY)
*
Time
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
00
30
I Would Like to Hire a:
*
Mobility Scooter
Powerchair
Wheelchair
Other
Control Position
Left
Right
I Would like to Hire the Following Mobility Aids:
Monkey Pole
4 Wheeled Stroller
Shower Chair/Commode
Bath Board
Toilet Seat Riser
Crutches
Your Approximate Weight
*
Under 21 st (134 kg or less)
21 st to 25 st (134 kg - 159 kg )
25 st to 28 st (159 kg - 178 kg)
28 st to 35 st (178 kg - 222 kg)
Over 35 st (222 kg or more)
Your Approximate Height
*
Under 6 feet (1.82 m)
Over 6 feet
Special Requirements
MobilityJaneLanzarote.com // mobility scooter lanzarote