Medical Equipment Request

The Narragansett Lions Club has limited Medical Equipment available for loan. If you need some Medical Equipment, please fill out the following form and submit, someone will get back to you shortly.

If you have any questions or requests for the Narragansett Lions Club, you can reach by either Email or US Mail.

Form to request Handicap equipment

Medical Equipment Requestor Name

Name(Required)

Prefix First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Home Phone

Mobile Phone(Required)

Equipment Needed

Equipment Requested (some are limited)

Cane

Commode

Walker

Walker w/ Seat

Wheelchair

Shower Seat

Other (describe below)

Describe "Other" equipment needed

Date Needed(Required)

Estimated Date Reurn(Required)

IMPORTANT:
Please Note: The Narragansett Lions Club has limited Medical Equipment available for loan. All Equipment is expected to be returned unless noted.

Please address any questions or concerns to the Club Secretary at: secretary@narragansettlionsclub.org. Thank you.

Your Electronic Signature

Full Name(Required)

Date Completed(Required)

CAPTCHA

To contact us via US Mail, please use the following address:
Narragansett Lions Club
P.O. Box 186
Narragansett, RI 02882