Safety Bed Quote Request - SLUMBER SERIES

Bed Series
*Mattress Choice
*Mattress Size *
*Safety Sides *
*Sleep Surface Function *
Head Location
Location determined when facing door from outside: left is standard
Bed Color *
*Feet *
Do you need clearance for floorlift?
Interior Padding
Pad Around Windows
(Doors ONLY)
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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