Reservation Form - Face-Down Positioning Rentals

To place your order online for Vitrectomy recovery equipment, please fill in the following form. Upon receiving your reservation, a Care Chairs representative will contact you to confirm details and schedule your delivery.

Please complete the following form:

Personal Information

*Required field Full Name:
*Required field Home Address:
*Required field City:
*Required field Province:
*Required field Postal Code:
*Required field Home Phone:
Business Phone:
Mobile Phone:
*Required field E-mail address:
*Required field Retinal Surgeon:
*Required field Hospital:
Date of Operation:

Delivery Information

Same as Above:	Yes No
If No,
Location Name:
Address:
City:
Province:
Postal Code:
Phone Number:

Delivery availability may vary

Equipment Required (Please mark box)

Face-Down Positioning Chair with Mirror

Face-Down Positioning Mat

Prism Glasses

*Required field Start Date:		Preferred Time:
End Date:		Preferred Time: