Safety Bed Quote Request - DREAM SERIES
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| Bed Series
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| *Mattress Size
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| *Mattress Choice
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| *Safety Sides
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| *Door Style
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| *Sleep Surface Function
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| *Transfer Height from floor
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| *Headboard Style
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| If canopy is desired, select straight headboard
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| Headboard Location
| Location determined when facing door from outside: left is standard
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| *Corner Post Style
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| *Wood
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| *Bed Color
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| Accent Carving Head/Foot
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| Accent Carving Doors
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| Engraving (enter text)
| text should be spelled and punctuated exactly as you wish it to appear on the headboard.
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| *Feet
*
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| Do you need clearance for floorlift?
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| Accessory
| IV pole Drawers (na for electric) Window in headboard Window in footboard Access port in headboard (for tubes) Access port in footboard (for tubes)
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| Interior Padding
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Pad Around Windows
(Doors ONLY)
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Mesh Safety Enclosure
(Fabric)
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Mesh Safety Enclosure
(Mesh)
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| *I am a
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| Parent Caregiver Therapist Medical Personnel Advocate DME Other
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| Quote Reference
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| Company Name
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| Contact Name
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| Prefix
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| First
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| Last
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| Suffix
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| Shipping Address
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| Address 2
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| City
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| State
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| Zip
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| Phone Number
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| *Contact e-mail
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| Quotes are emailed to this address
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| Do you have a forklift or dock?
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| Plan to submit to insurance
*
| Private insurance, Medicaid, Waiver, etc.
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| Comment / Notes
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