Hospital Bed and Mattress Questionnaire

Not sure what bed or mattress is the right fit for you?

Please fill out the questionnaire below and a Sales Representative will contact you with a quote or may need to call you with more clarifying questions.

Not sure what bed or mattress is the right fit for you?

Please fill out the questionnaire below and a Sales Representative will contact you with a quote or may need to call you with more clarifying questions.

Purchase or Rental? *

Purchase

Rental

What size bed/mattress are you looking for? *

Single

Full

Queen

King

Can the user self-transfer in and out of bed? *

Yes

Can the user self-reposition in bed? *

Yes

How many hours a day is the user in bed? *

Does the user currently or in the past have any redness, pressure areas, or open wounds? *

Yes

Does the user have impaired sensation? *

Yes

What options are important to you? *

Positioning

Railings

Height Range (Hi/Lo)

HomeCare or Facility type bed

Aesthetics

Other

What is the user's height?

What is the user's weight? *

Where does the user live? *

Home

Senior Living Facility

Your Name *

Your Email *

Phone Number *

Subject *

Submit

Ready for Delivery?

Fill out the Hospital Bed Delivery form to ensure we can safely transport the bed or mattress.

Delivery Information

Hospital Bed & Mattress Questionnaire

Hospital Bed & Mattress Questionnaire

Not sure what bed or mattress is the right fit for you?

Not sure what bed or mattress is the right fit for you?

Ready for Delivery?

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