EmailMe Form - Safety Bed Quote Request

Bed Series

*Mattress Size *

*Mattress Choice

*Mattress Hold Down System (fixed deck only)

*Sleep Surface Function *

Horizontal Shroud
(wood bar at top of bed)

Head Location

Location when facing door from outside: left is standard

Fabric Color

Mesh options *

Bed Color *

*Feet *

Floor lift clearance

Exterior Padding on Frame

Additional Doors

Head

Foot

Back

One door is standard, can add additional doors

Sensory Curtains
(reduces sensory input)

Accessory

*I am a *

Quote/Job Reference *

Name *

First Last

Company Name

Shipping Address *

Shipping Address

City *

State *

Zip *

Phone Number *

### - ### - ####

*Contact e-mail *

Quotes are emailed to this address

Do you have a forklift or dock? *

Is this a residential address? *

Comments

Plan to submit to insurance