Hospital Bed & 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.

Hospital Bed & Mattress Questionnaire

Purchase or Rental? *

Purchase

Rental

What size bed are you looking for? *

Single

Full

Queen

King

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

Yes

What options are important to you? *

Positioning

Railings

Height Range (Hi/Lo)

HomeCare or Facility type bed

Aesthetics

Other

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

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

Yes

Can the user self-reposition in bed? *

Yes

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 size mattress are you looking for? *

Twin

Full

Queen

King

What is the user's height?

What is the user's weight? *

Your Name *

Your Email *

Phone Number *

Subject *

Submit