Medical Equipment Loan Form

Medical Equipment Loan Form

Need Medical Equipment? We've Got You Covered.

Whether you are recovering from an injury, caregiving for someone you love, or know someone else in need of medical equipment, GESMV is here to help. Please complete the form below to request items from our rotating inventory and someone from our team will reach out to help you schedule a pickup time. 

Reach us by phone

Call: 937.528.6371
Name ( First and Last):
Phone:
Email:
Which city are you closer to DAYTON or LIMA:
Best Time of Day to Contact::
Please select the medical equipment you are requesting.
Mobility Assistance
Wheelchair with Elevated Leg Rests
Wheelchair with Standard Foot Rests
Transport Wheelchair
Quad Cane
Single Point Cane
Crutches
Forearm Crutches
Deluxe Walker (4 wheels with feet)
Standard Walker (with or without wheels)
Toilet Assistance
Toilet Rails
Elevated Toilet Seat
Commode
Over the Toilet/Bedside
Tub and Shower Assistance
Tub Seat
Tub Stool
Transfer Bench
Daily Living Assistance
Shoe Horn
Sock Aids
Reacher
Bed Rails/Tub Rails