Need Help?

Clinics Can Help maintains a large Lending Closet that includes a wide variety of Durable Medical Equipment (DME) that is available for short and long-term loan. We also maintain an ever-changing inventory of single-use medical supplies that may be appropriate for your needs.

Equipment and supplies that we regularly have in stock:

  • Wheelchairs (adult, child, electric, specialty chairs)
  • Adaptive Strollers
  • Walkers
  • Canes and Crutches
  • Hospital Beds
  • Shower Chairs
  • Nebulizers
  • Patient Lifts and Lift Chairs
  • Wound Care and General Healthcare Supplies
  • Incontinent Supplies
  • Braces of All Kinds
  • Toilet Seat Risers
  • Gel Mattresses

Please Note: We may have other non-standard items in our inventory, so please provide any additional details or needs that you may have in the “Additional Information” section below. Or, you can contact us directly with your specific needs.

Please complete the Online Equipment Request Form below and then click “SUBMIT REQUEST“. We will contact you promptly to confirm your request.

Note: Please do not print this page. If you would like to print out an equipment request form, please scroll to the bottom of this page for a downloadable PDF version.

- Online Equipment Request Form -

Equipment Request Form [NEW]

Your information

Please provide the following information so that we may contact you if we have any follow up questions

Recipient's Information

Please provide the following information about the person in need of medical equipment.

Equipment Requested

Please let us know what types of equipment and/or supplies you need.

* Note: Hospital bed refers to a frame, mattress and side rails. Patient lifts may be manual or electric, availability depends on inventory.

* Note: Walker refers to: Rolling Walker, Rolling Seated Walker or Hemi-Walker.

Recipient's Insurance and Demographic Information

To provide our funders with the most accurate information about the people we serve please complete the following questions.

Disclaimer

I acknowledge that the above-identified equipment will be inspected by me, or the responsible person noted above, at the time the equipment is received to ensure cleanliness and that it is in good operating condition. I agree that I will return the equipment in the same condition when my (or my child's) present physical need no longer exists. I will not permit this equipment to be transferred to another person under any circumstances, and while this equipment is in my possession, I will notify you of any change of address for me. I will not take this equipment out of the area served by Clinics Can Help. I hereby release and hold harmless Clinics Can Help, its members, agents, or employees from any claim by me, or any person acting for me or on my behalf for any loss, expense, or damage, including but not limited to general, specific, incidental, or consequential damages, of any kind or nature whatsoever arising from this equipment or its use. I agree that Clinics Can Help, its members, agents, volunteers or employees have made no representation of any kind whatsoever expressed or implied, to me with regard to the condition of the equipment provided or as to the use to which the equipment is to be put. I also give Clinics Can Help permission to take my photo and to use it in any and all promotional venues.

Sign Here

IMPORTANT: Please click the "Submit Request" button after completing all required fields above. We will not receive your request unless you submit your request.

Please DO NOT PRINT this online form. If you would like to print out a form, please click on the link below to download a printable version.

If you would prefer to print out a form, please CLICK HERE for a downloadable and printable form.