Safety Bed Quote Request - SLUMBER SERIES

Bed Series
*Mattress Size *
*Safety Sides *
*Sleep Surface Function *
*Feet *
Do you need clearance for floorlift?
Interior Padding
Mesh Safety Enclosure (fabric color)
Mesh Safety Enclosure (mesh choice)
 IV pole 
 Access port in headboard 
 Access port in footboard 
*I am a *
 Medical Personnel 
 Potential User 
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? *
Plan to submit to insurance
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