CR Newton Orthotics, Prosthetics and Medical Equipment

Please send us this form to reserve our products while you are in Hawaii.

First Name:	Last Name:
E-mail address:
Home Address:
City:	State:	Zip Code:

Home Phone Number: - -

Rental Equipment User's Information:

First Name:	Last Name:
Height:		Weight:

Type of Equipment Needed:

[To see rental prices and a larger image of each product, click on a photo]

Standard Wheelchair Companion Wheelchair Crutches

Heavy Duty Wheelchair Reclining Wheelchair Hemi Wheelchair

Lightweight Wheelchair Pediatric Wheelchair Beach Wheelchair

High Str. Wheelchair Battery Charger IV Pole

Ramp (5 or 7 foot) Electric Wheelchair (right hand control) Electric Wheelchair (left hand control)

Elevated Legrest (right) Elevated Legrest (left) Elevated Legrest (both)

Hospital Bed 3-wheel scooters 4-wheel scooters

Four Wheeled Walker Walker with Wheels Walker without Wheels

Trapeze Bar Patient Lift

Hotel Name:

Hotel Room Number:

Guest Arrival Date: - -	Time:
Guest Departure Date: - -	Time:

Questions/Comments

Please Indicate Method of Payment:

VISA
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AMEX

JCB

Discover

Credit Card Number:

Name on Card:

Expiration Date: -

This information is transmitted via a secure server (SSL).

Guarantee of Privacy

CR Newton Co, Ltd respects your privacy and guarantees that all personal information that you provide us with is kept confidential and will not be used in ways to which you have not consented. We will not disclose or sell any information that identifies you to an unrelated third party without your approval. In addition, your credit card and password information is kept strictly confidential. CR Newton Co, Ltd uses the latest encryption technologies, rigorous password protection and limits the number of people who have access to your information in order to guard against unauthorized access to your data.

Mahalo!

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Orthotics, Prosthetics and Medical Equipment
808-949-8389 800-545-2078
1575 South Beretania Street
Honolulu, HI 96826

Please email us with any questions or comments