mexicomobility.com
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160.153.63.8
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Submitted URL: https://accessibility.com.mx/
Effective URL: https://mexicomobility.com/
Submission: On October 11 via api from US — Scanned from DE
Effective URL: https://mexicomobility.com/
Submission: On October 11 via api from US — Scanned from DE
Form analysis 3 forms found in the DOM
POST /#gf_14
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_14" id="gform_14" action="/#gf_14" data-formid="14" novalidate="">
<div id="gf_page_steps_14" class="gf_page_steps">
<div id="gf_step_14_1" class="gf_step gf_step_active gf_step_first"><span class="gf_step_number">1</span><span class="gf_step_label">Rental Date and Time</span></div>
<div id="gf_step_14_2" class="gf_step gf_step_next gf_step_pending"><span class="gf_step_number">2</span><span class="gf_step_label">Select a Scooter, Wheelchair & etc.</span></div>
<div id="gf_step_14_3" class="gf_step gf_step_pending"><span class="gf_step_number">3</span><span class="gf_step_label">Rental Location</span></div>
<div id="gf_step_14_4" class="gf_step gf_step_last gf_step_pending"><span class="gf_step_number">4</span><span class="gf_step_label">Profile Information</span></div>
</div>
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_page_14_1" class="gform_page forma-1-strana" data-js="page-field-id-1">
<div class="gform_page_fields">
<ul id="gform_fields_14" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_14_92"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-custom-icon kalendar-slk gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_92"><label class="gfield_label gform-field-label" for="input_14_92">Delivery Date<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_92" id="input_14_92" type="text" value="10/11/2024" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy"
aria-describedby="input_14_92_date_format gfield_description_14_92" aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://mexicomobility.com/wp-content/uploads/2015/02/1423067238_calendar-64.png"
alt="Select date" title="Select date">
<span id="input_14_92_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_14_92" class="gform_hidden" value="https://mexicomobility.com/wp-content/uploads/2015/02/1423067238_calendar-64.png">
<div class="gfield_description" id="gfield_description_14_92">Date when Rental Begins. *Minimum rental is 3 Calendar days*</div>
</li>
<li id="field_14_2"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-custom-icon kalendar-slk gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_2"><label class="gfield_label gform-field-label" for="input_14_2">Return Date<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_2" id="input_14_2" type="text" value="10/11/2024" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy"
aria-describedby="input_14_2_date_format gfield_description_14_2" aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://mexicomobility.com/wp-content/uploads/2015/02/1423067238_calendar-64.png"
alt="Select date" title="Select date">
<span id="input_14_2_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_14_2" class="gform_hidden" value="https://mexicomobility.com/wp-content/uploads/2015/02/1423067238_calendar-64.png">
<div class="gfield_description" id="gfield_description_14_2">Date when Rental Ends. *Minimum rental is 3 Calendar days*</div>
</li>
<li id="field_14_188" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_188"><label class="gfield_label gform-field-label" for="input_14_188">Tell us What you are looking for?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_188" id="input_14_188" class="medium gfield_select" aria-describedby="gfield_description_14_188" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Mobility Scooter">Mobility Scooter</option>
<option value="Wheelchair">Wheelchair</option>
<option value="Personal Transporter Unit (For Non-disabled ONLY)">Personal Transporter Unit (For Non-disabled ONLY)</option>
<option value="Rollator / Walker">Rollator / Walker</option>
<option value="Oxygen Concentrator">Oxygen Concentrator</option>
<option value="CPAP Machine">CPAP Machine</option>
<option value="CPAP Supplies">CPAP Supplies</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_188">Indicate if you are not a disabled traveler and if you are looking for a personal transporter device.</div>
</li>
<li id="field_14_66" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_66"><label class="gfield_label gform-field-label" for="input_14_66">Add an Oxygen Device?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_66" id="input_14_66" class="small gfield_select" aria-describedby="gfield_description_14_66" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_66">If yes, you will be ask for more details later in the form.</div>
</li>
<li id="field_14_55" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_55"><label class="gfield_label gform-field-label" for="input_14_55">City of Service<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_55" id="input_14_55" class="small gfield_select" aria-describedby="gfield_description_14_55" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select City</option>
<option value="Los Cabos, Mexico">Los Cabos, Mexico</option>
<option value="Cancun, Mexico">Cancun, Mexico</option>
<option value="Cozumel, Mexico">Cozumel, Mexico</option>
<option value="Puerto Vallarta, Mexico">Puerto Vallarta, Mexico</option>
<option value="La Paz, Mexico">La Paz, Mexico</option>
<option value="Loreto, Mexico">Loreto, Mexico</option>
<option value="Mazatlan, Mexico">Mazatlan, Mexico</option>
<option value="Merida, Mexico">Merida, Mexico</option>
<option value="Playa Del Carmen, Mexico">Playa Del Carmen, Mexico</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_55">Indicate First If You'd like to ADD an Oxygen Device or not in order to see ALL CITIES LISTED.</div>
</li>
<li id="field_14_260" class="gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_14_260">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label" for="input_14_260">Number of Days</label>
<div class="ginput_container ginput_container_number"><input name="input_260" id="input_14_260" type="text" step="any" value="" class="small" readonly="readonly" aria-invalid="false"></div>
</li>
<li id="field_14_261"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_261">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/06/1210584_alert_attention_caution_error_exclamation_icon-2.png" alt=""></ul>
<ul>
<p>NEXT BUTTON WON'T SHOW IF RENTAL IS FOR LESS THAN 3 CALENDAR DAYS!!!!!!.</p>
</ul>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-NEXT-BUTTON-MINI.png" id="gform_next_button_14_5" class="gform_next_button gform-theme-button button gform_image_button" alt="Next Page"
onclick="jQuery("#gform_target_page_number_14").val("2"); jQuery("#gform_14").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_14").val("2"); jQuery("#gform_14").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_14_2" class="gform_page forma-2-strana" data-js="page-field-id-5" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_14_2" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_14_262"
class="gfield gfield--type-number gfield--input-type-number gfield--width-full form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_262"><label class="gfield_label gform-field-label" for="input_14_262">User's Weight in Lbs<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_262" id="input_14_262" type="number" step="any" min="31" max="600" value="" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_14_262 gfield_description_14_262">
<div class="gfield_description instruction " id="gfield_instruction_14_262">Please enter a number from <strong>31</strong> to <strong>600</strong>.</div>
</div>
<div class="gfield_description" id="gfield_description_14_262">Check weight capacity limits. (KgsX2.2=Lbs)</div>
</li>
<li id="field_14_8" class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_8"><label class="gfield_label gform-field-label" for="input_14_8">Describe Your Mobility Disability<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_8" id="input_14_8" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select one</option>
<option value="Limited Walking Capacity" selected="selected">Limited Walking Capacity</option>
<option value="Elderly">Elderly</option>
<option value="Absent limb/reduced limb function">Absent limb/reduced limb function</option>
<option value="Paraplegia">Paraplegia</option>
<option value="Quadriplegia">Quadriplegia</option>
<option value="Hemiplegia">Hemiplegia</option>
<option value="Dystrophy">Dystrophy</option>
<option value="Other">Other</option>
</select></div>
</li>
<li id="field_14_263"
class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full travel3-wrap gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_14_263"><label class="gfield_label gform-field-label gfield_label_before_complex">Describe your Mobility Limitation<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_14_263">Describe your Mobility Limitation - Check all the boxes that describe your mobility issues.</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_14_263">
<li class="gchoice gchoice_select_all">
<input class="gfield-choice-input" type="checkbox" id="choice_263_select_all" onclick="gformToggleCheckboxes( this )" onkeypress="gformToggleCheckboxes( this )">
<label for="choice_263_select_all" id="label_263_select_all" class="gform-field-label gform-field-label--type-inline" data-label-select="Select All" data-label-deselect="Deselect All">Select All</label>
</li>
<li class="gchoice gchoice_14_263_1">
<input class="gfield-choice-input" name="input_263.1" type="checkbox" value="Age +65 yo" id="choice_14_263_1" aria-describedby="gfield_description_14_263">
<label for="choice_14_263_1" id="label_14_263_1" class="gform-field-label gform-field-label--type-inline">Age +65 yo</label>
</li>
<li class="gchoice gchoice_14_263_2">
<input class="gfield-choice-input" name="input_263.2" type="checkbox" value="Bad knees, hips or back" id="choice_14_263_2">
<label for="choice_14_263_2" id="label_14_263_2" class="gform-field-label gform-field-label--type-inline">Bad knees, hips or back</label>
</li>
<li class="gchoice gchoice_14_263_3">
<input class="gfield-choice-input" name="input_263.3" type="checkbox" value="Can't walk long distances" id="choice_14_263_3">
<label for="choice_14_263_3" id="label_14_263_3" class="gform-field-label gform-field-label--type-inline">Can't walk long distances</label>
</li>
<li class="gchoice gchoice_14_263_4">
<input class="gfield-choice-input" name="input_263.4" type="checkbox" value="Recent Major surgery (less than 2 months)" id="choice_14_263_4">
<label for="choice_14_263_4" id="label_14_263_4" class="gform-field-label gform-field-label--type-inline">Recent Major surgery (less than 2 months)</label>
</li>
<li class="gchoice gchoice_14_263_5">
<input class="gfield-choice-input" name="input_263.5" type="checkbox" value="Post Stroke Paralysis" id="choice_14_263_5">
<label for="choice_14_263_5" id="label_14_263_5" class="gform-field-label gform-field-label--type-inline">Post Stroke Paralysis</label>
</li>
<li class="gchoice gchoice_14_263_6">
<input class="gfield-choice-input" name="input_263.6" type="checkbox" value="Multiple Sclerosis (MS)" id="choice_14_263_6">
<label for="choice_14_263_6" id="label_14_263_6" class="gform-field-label gform-field-label--type-inline">Multiple Sclerosis (MS)</label>
</li>
<li class="gchoice gchoice_14_263_7">
<input class="gfield-choice-input" name="input_263.7" type="checkbox" value="Lower Limb Paralysis / absent" id="choice_14_263_7">
<label for="choice_14_263_7" id="label_14_263_7" class="gform-field-label gform-field-label--type-inline">Lower Limb Paralysis / absent</label>
</li>
<li class="gchoice gchoice_14_263_8">
<input class="gfield-choice-input" name="input_263.8" type="checkbox" value="Any Motor Disability" id="choice_14_263_8">
<label for="choice_14_263_8" id="label_14_263_8" class="gform-field-label gform-field-label--type-inline">Any Motor Disability</label>
</li>
<li class="gchoice gchoice_14_263_9">
<input class="gfield-choice-input" name="input_263.9" type="checkbox" value="None of the above" id="choice_14_263_9">
<label for="choice_14_263_9" id="label_14_263_9" class="gform-field-label gform-field-label--type-inline">None of the above</label>
</li>
</ul>
</div>
</li>
<li id="field_14_264"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_264">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>STAND N RIDE NOT RECOMMENDED IF YOU HAVE ANY OF THE LISTED CONDITIONS/DISABILITIES!</p>
</ul>
</li>
<li id="field_14_138"
class="gfield gfield--type-product gfield--input-type-select form-li-wrapped gfield_price gfield_price_14_138 gfield_product_14_138 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_138"><label class="gfield_label gform-field-label" for="input_14_138">Select Oxygen Device<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_138" id="input_14_138" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Stationary Oxygen Concentrator|0">Stationary Oxygen Concentrator</option>
<option value="Portable Oxygen Concentrator|0">Portable Oxygen Concentrator</option>
<option value="CPAP Machine|0">CPAP Machine</option>
</select></div>
</li>
<li id="field_14_265"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-li-wrapped gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_265">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/06/OXYGEN-TYPES-TRANS-e1719159369904.png" alt=""></ul>
</li>
<li id="field_14_84" class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_84"><label class="gfield_label gform-field-label" for="input_14_84">Therapy Frequency<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_84" id="input_14_84" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="24 hours">24 hours</option>
<option value="At Night">At Night</option>
<option value="Occasionally">Occasionally</option>
</select></div>
</li>
<li id="field_14_86" class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_86"><label class="gfield_label gform-field-label" for="input_14_86">Oxygen Rate<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_86" id="input_14_86" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="1-3 lts per minute">1-3 lts per minute</option>
<option value="4-5 lts per minute">4-5 lts per minute</option>
<option value="> 5lts per minute">> 5lts per minute</option>
<option value="CPAP without Oxygen">CPAP without Oxygen</option>
</select></div>
</li>
<li id="field_14_266"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full travel3-wrap gfield_price gfield_price_14_266 gfield_product_14_266 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_266"><label class="gfield_label gform-field-label">CPAP Mask (Nasal)</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_266">
<li class="gchoice gchoice_14_266_0">
<input name="input_266" type="radio" value="CPAP Mask (Nasal)|0" id="choice_14_266_0">
<label for="choice_14_266_0" id="label_14_266_0" class="gform-field-label gform-field-label--type-inline">CPAP Mask (Nasal)</label>
</li>
</ul>
</div>
</li>
<li id="field_14_151"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_151">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2024/07/CPAP-NASAL-MASK.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Premium Headgear.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Forehead Cushion: Silicone.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Gel Cushion: Urethane Gel; EVA.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Exhalation Elbow and Swivel: Polycarbonate. </p>
</li>
</ul>
</li>
<li id="field_14_267"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full standard-wrap gfield_price gfield_price_14_267 gfield_product_14_267 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_267"><label class="gfield_label gform-field-label">CPAP tubing</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_267">
<li class="gchoice gchoice_14_267_0">
<input name="input_267" type="radio" value="CPAP tubing|0" id="choice_14_267_0">
<label for="choice_14_267_0" id="label_14_267_0" class="gform-field-label gform-field-label--type-inline">CPAP tubing</label>
</li>
</ul>
</div>
</li>
<li id="field_14_165"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item standard-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_165">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2024/07/CPAP-TUBING.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Length: 6 ft (72 in).</p>
</li>
<li><i class="fa fa-check"></i>
<p>NOT compatible with a machine that requires a 15mm hose.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Latex Free.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Diameter: 19mm. </p>
</li>
</ul>
</li>
<li id="field_14_318"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full heavy-wrap gfield_price gfield_price_14_318 gfield_product_14_318 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_318"><label class="gfield_label gform-field-label">CPAP Mask + Tubing</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_318">
<li class="gchoice gchoice_14_318_0">
<input name="input_318" type="radio" value="CPAP Mask + Tubing|0" id="choice_14_318_0">
<label for="choice_14_318_0" id="label_14_318_0" class="gform-field-label gform-field-label--type-inline">CPAP Mask + Tubing</label>
</li>
</ul>
</div>
</li>
<li id="field_14_319"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item heavy-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_319">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2024/07/MASK-TUBING-TRANS.png" alt=""></li>
</ul>
</li>
<li id="field_14_166" class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_166"><label class="gfield_label gform-field-label" for="input_14_166">Do you Know your CPAP Settings?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_166" id="input_14_166" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="I use an AUTO-CPAP">I use an AUTO-CPAP</option>
<option value="Not Sure">Not Sure</option>
</select></div>
</li>
<li id="field_14_173"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_173"><label class="gfield_label gform-field-label" for="input_14_173">What Pressure your CPAP is set up?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_173" id="input_14_173" class="small gfield_select" aria-describedby="gfield_description_14_173" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_173">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_168"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_168"><label class="gfield_label gform-field-label" for="input_14_168">Does your CPAP has the Ramp setting ON?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_168" id="input_14_168" class="small gfield_select" aria-describedby="gfield_description_14_168" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="I Do not know">I Do not know</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_168">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_169"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_169"><label class="gfield_label gform-field-label" for="input_14_169">Minutes of Ramp your CPAP is set up?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_169" id="input_14_169" class="small gfield_select" aria-describedby="gfield_description_14_169" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="1 minute">1 minute</option>
<option value="2 minutes">2 minutes</option>
<option value="3 minutes">3 minutes</option>
<option value="4 minutes">4 minutes</option>
<option value="5 minutes">5 minutes</option>
<option value="6 minutes">6 minutes</option>
<option value="7 minutes">7 minutes</option>
<option value="8 minutes">8 minutes</option>
<option value="9 minutes">9 minutes</option>
<option value="10 minutes">10 minutes</option>
<option value="I Do not know">I Do not know</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_169">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_170"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_170"><label class="gfield_label gform-field-label" for="input_14_170">Indicate Pressure the Ramp is set?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_170" id="input_14_170" class="small gfield_select" aria-describedby="gfield_description_14_170" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="I Do Not Know">I Do Not Know</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_170">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_167"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_167"><label class="gfield_label gform-field-label" for="input_14_167">Do you use a Humidifier with your CPAP?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_167" id="input_14_167" class="small gfield_select" aria-describedby="gfield_description_14_167" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="I Do not Know">I Do not Know</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_167">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_174"
class="gfield gfield--type-select gfield--input-type-select form-li-wrapped gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_174"><label class="gfield_label gform-field-label" for="input_14_174">Do you use your CPAP with supplemental Oxygen?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_174" id="input_14_174" class="small gfield_select" aria-describedby="gfield_description_14_174" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="I Do not Know">I Do not Know</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_174">This information is important to set up your device before shipping it to YOU. If you do not know it, We will set up the CPAP at an average setting that can Help you while you
are abroad.</div>
</li>
<li id="field_14_171"
class="gfield gfield--type-product gfield--input-type-select form-li-wrapped gfield_price gfield_price_14_171 gfield_product_14_171 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_171"><label class="gfield_label gform-field-label" for="input_14_171">Add CPAP Mask?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_171" id="input_14_171" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes|0">Yes</option>
<option value="No|0">No</option>
</select></div>
</li>
<li id="field_14_172"
class="gfield gfield--type-product gfield--input-type-select form-li-wrapped gfield_price gfield_price_14_172 gfield_product_14_172 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_172"><label class="gfield_label gform-field-label" for="input_14_172">Add CPAP Tubing?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_172" id="input_14_172" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes|0">Yes</option>
<option value="No|0">No</option>
</select></div>
</li>
<li id="field_14_139"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio travel3-wrap gfield_price gfield_price_14_139 gfield_product_14_139 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_139"><label class="gfield_label gform-field-label">Everflo Stationary Oxygen Concentrator</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_139">
<li class="gchoice gchoice_14_139_0">
<input name="input_139" type="radio" value="Everflo Stationary Oxygen Concentrator|0" id="choice_14_139_0">
<label for="choice_14_139_0" id="label_14_139_0" class="gform-field-label gform-field-label--type-inline">Everflo Stationary Oxygen Concentrator</label>
</li>
</ul>
</div>
</li>
<li id="field_14_75"
class="gfield gfield--type-html gfield--input-type-html form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_75">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/05/EVERFLO-2.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Easy to store, transport, and deliver.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Interface panel with on/off switch and alarm indicators.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Recessed flow meter reduces the risk of breakage.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Metal cannula connector for greater durability.</p>
</li>
</ul>
</li>
<li id="field_14_233"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full travel3-wrap gfield_price gfield_price_14_233 gfield_product_14_233 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_233"><label class="gfield_label gform-field-label">Rollator Lite</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_233">
<li class="gchoice gchoice_14_233_0">
<input name="input_233" type="radio" value="Rollator Lite|0" id="choice_14_233_0">
<label for="choice_14_233_0" id="label_14_233_0" class="gform-field-label gform-field-label--type-inline">Rollator Lite</label>
</li>
</ul>
</div>
</li>
<li id="field_14_238"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_238">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2023/02/ROLLATOR-ULTRA-TRANS.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Rolling Walker with Seat: Stable, strong and stylish.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Steel rollator features a durable and supportive frame.</p>
</li>
<li><i class="fa fa-check"></i>
<p> A comfortable seat, and an under-seat storage pouch.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Great walker for seniors and adults seeking stability.</p>
</li>
</ul>
</li>
<li id="field_14_235"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full standard-wrap gfield_price gfield_price_14_235 gfield_product_14_235 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_235"><label class="gfield_label gform-field-label">Rollator Heavy Duty</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_235">
<li class="gchoice gchoice_14_235_0">
<input name="input_235" type="radio" value="Rollator Heavy Duty|0" id="choice_14_235_0">
<label for="choice_14_235_0" id="label_14_235_0" class="gform-field-label gform-field-label--type-inline">Rollator Heavy Duty</label>
</li>
</ul>
</div>
</li>
<li id="field_14_237"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item standard-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_237">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2023/02/ROLLATOR-HEAVY-DUTY-ULTRA-TRANS.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Rolling Rollator/Walker with Seat: 500 lbs. weigth Capacity.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Steel rollator features a durable and supportive frame.</p>
</li>
<li><i class="fa fa-check"></i>
<p> A comfortable seat, and an under-seat storage pouch.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Great walker for Heavy seniors and adults seeking stability.</p>
</li>
</ul>
</li>
<li id="field_14_234"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full heavy-wrap gfield_price gfield_price_14_234 gfield_product_14_234 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_234"><label class="gfield_label gform-field-label">Rollator-Wheelchair Combo</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_234">
<li class="gchoice gchoice_14_234_0">
<input name="input_234" type="radio" value="Rollator-Wheelchair Combo|0" id="choice_14_234_0">
<label for="choice_14_234_0" id="label_14_234_0" class="gform-field-label gform-field-label--type-inline">Rollator-Wheelchair Combo</label>
</li>
</ul>
</div>
</li>
<li id="field_14_236"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full form-item heavy-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_236">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2023/02/Rollator-WC-combo-ULTRTA-TRANS.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Walker-Wheelchair Combo: Stylish rolling walker with seat combines the features of a rollator and transport chair in one unit.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Steel rollator features a durable and supportive frame.</p>
</li>
<li><i class="fa fa-check"></i>
<p> A comfortable seat, and an under-seat storage pouch.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Great walker for seniors and adults seeking stability.</p>
</li>
</ul>
</li>
<li id="field_14_189"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio standard-wrap gfield_price gfield_price_14_189 gfield_product_14_189 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_189"><label class="gfield_label gform-field-label">STAND-N-RIDE SCOOTER<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_189">
<li class="gchoice gchoice_14_189_0">
<input name="input_189" type="radio" value="STAND-N-RIDE SCOOTER|0" id="choice_14_189_0">
<label for="choice_14_189_0" id="label_14_189_0" class="gform-field-label gform-field-label--type-inline">STAND-N-RIDE SCOOTER</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_14_189">Personal Transporter for NON-DISABLED ADULT USERS ONLY!</div>
</li>
<li id="field_14_190"
class="gfield gfield--type-html gfield--input-type-html form-item standard-wrap gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_190">
<ul>
<li><img src="https://www.mexicomobility.com/wp-content/themes/mobility/images/EW-18 CROPPED.gif
" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>For user's weighting 260 lbs or less ONLY.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Smooth, Quiet, Non-Intrusive.</p>
</li>
<li><i class="fa fa-check"></i>
<p>15 MPH Top Speed.</p>
</li>
<li><i class="fa fa-check"></i>
<p>20 miles battery range.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Removable Seat for Free Standing operation.</p>
</li>
</ul>
</li>
<li id="field_14_193"
class="gfield gfield--type-html gfield--input-type-html travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_193">
<ul>
<li><img src="https://www.mexicomobility.com/wp-content/themes/mobility/images/MAX WEIGHT 260-2.png
" alt=""></li>
</ul>
<ul>
<p>Select a STANDARD or HD SCOOTER instead.</p>
</ul>
</li>
<li id="field_14_141"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio standard-wrap gfield_price gfield_price_14_141 gfield_product_14_141 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_141"><label class="gfield_label gform-field-label">CPAP Machine<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_141">
<li class="gchoice gchoice_14_141_0">
<input name="input_141" type="radio" value="CPAP Machine|0" id="choice_14_141_0">
<label for="choice_14_141_0" id="label_14_141_0" class="gform-field-label gform-field-label--type-inline">CPAP Machine</label>
</li>
</ul>
</div>
</li>
<li id="field_14_83"
class="gfield gfield--type-html gfield--input-type-html form-item standard-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_83">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/05/RESMED.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>weighs only a pound and a half.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Ramp from 4cm up to CPAP pressure</p>
</li>
<li><i class="fa fa-check"></i>
<p>Altitude Compensation Automatic.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Dimensions 5.6" x 2.9" x 7.7" </p>
</li>
</ul>
</li>
<li id="field_14_163"
class="gfield gfield--type-html gfield--input-type-html form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_163">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/07/CPAP-NASAL-MASK.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Premium Headgear.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Forehead Cushion: Silicone.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Gel Cushion: Urethane Gel; EVA.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Exhalation Elbow and Swivel: Polycarbonate. </p>
</li>
</ul>
</li>
<li id="field_14_153"
class="gfield gfield--type-html gfield--input-type-html form-item transport-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_153">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/07/CPAP-TUBING.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Length: 6 ft (72 in).</p>
</li>
<li><i class="fa fa-check"></i>
<p>NOT compatible with a machine that requires a 15mm hose.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Latex Free.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Diameter: 19mm. </p>
</li>
</ul>
</li>
<li id="field_14_140"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio heavy-wrap gfield_price gfield_price_14_140 gfield_product_14_140 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_140"><label class="gfield_label gform-field-label">Portable Oxygen Concentrator</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_140">
<li class="gchoice gchoice_14_140_0">
<input name="input_140" type="radio" value="Portable Oxygen Concentrator|0" id="choice_14_140_0">
<label for="choice_14_140_0" id="label_14_140_0" class="gform-field-label gform-field-label--type-inline">Portable Oxygen Concentrator</label>
</li>
</ul>
</div>
</li>
<li id="field_14_81"
class="gfield gfield--type-html gfield--input-type-html form-item heavy-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_81">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/05/SIMPLY-GO.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>MAX 2 litter per minute in Continous flow.</p>
</li>
<li><i class="fa fa-check"></i>
<p>FAA aproved.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Easy Access to Batteries.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Lightweight less than 10 pounds.</p>
</li>
</ul>
</li>
<li id="field_14_120"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio standard-wrap gfield_price gfield_price_14_120 gfield_product_14_120 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_120"><label class="gfield_label gform-field-label">Standard Wheelchair</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_120">
<li class="gchoice gchoice_14_120_0">
<input name="input_120" type="radio" value="Standard Wheelchair|0" id="choice_14_120_0">
<label for="choice_14_120_0" id="label_14_120_0" class="gform-field-label gform-field-label--type-inline">Standard Wheelchair</label>
</li>
</ul>
</div>
</li>
<li id="field_14_43"
class="gfield gfield--type-html gfield--input-type-html form-item standard-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_43">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/STANDARD-WHEELCHAIR-CHECKFRONT.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Standard Wheelchair is designed to meet the needs of active users. It’s‚ lightweight and easily fits into a Taxi.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Highly durable, enhanced fit and function with 300 Lbs Capacity. Elevated leg rest available.</p>
</li>
</ul>
</li>
<li id="field_14_199"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio heavy-wrap gfield_price gfield_price_14_199 gfield_product_14_199 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_199"><label class="gfield_label gform-field-label">HD Wheelchair</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_199">
<li class="gchoice gchoice_14_199_0">
<input name="input_199" type="radio" value="HD Wheelchair|0" id="choice_14_199_0">
<label for="choice_14_199_0" id="label_14_199_0" class="gform-field-label gform-field-label--type-inline">HD Wheelchair</label>
</li>
</ul>
</div>
</li>
<li id="field_14_198"
class="gfield gfield--type-html gfield--input-type-html form-item heavy-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_198">
<ul>
<li><img src="https://www.mexicomobility.com/wp-content/themes/mobility/images/HD WHEELCHAIR 2.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>HD Wheelchair is designed to meet your needs.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Highly durable, enhanced fit and function with 450 Lbs Capacity.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Weight 31 Lbs with standard Legrest.</p>
</li>
</ul>
</li>
<li id="field_14_219"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio travel3-wrap gfield_price gfield_price_14_219 gfield_product_14_219 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_219"><label class="gfield_label gform-field-label">Travel 4 Wheels Scooter</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_219">
<li class="gchoice gchoice_14_219_0">
<input name="input_219" type="radio" value="Travel 4 Wheels Scooter|0" id="choice_14_219_0">
<label for="choice_14_219_0" id="label_14_219_0" class="gform-field-label gform-field-label--type-inline">Travel 4 Wheels Scooter</label>
</li>
</ul>
</div>
</li>
<li id="field_14_44"
class="gfield gfield--type-html gfield--input-type-html form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_44">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/TRAVEL-SCOOTER-GOGO-CHECKFRONT.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>4 Wheel Design Allows for a Highly Maneuverable 34nch Turning Radius, with 260Lbs Capacity</p>
</li>
<li><i class="fa fa-check"></i>
<p>Top Speed of 4.5 MPH / Range of 12 Miles</p>
</li>
<li><i class="fa fa-check"></i>
<p> Fully Disassemble to 4 Pieces.</p>
</li>
</ul>
</li>
<li id="field_14_128"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio heavy-wrap gfield_price gfield_price_14_128 gfield_product_14_128 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_128"><label class="gfield_label gform-field-label">Heavy Duty Scooter</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_128">
<li class="gchoice gchoice_14_128_0">
<input name="input_128" type="radio" value="Heavy Duty Scooter|0" id="choice_14_128_0">
<label for="choice_14_128_0" id="label_14_128_0" class="gform-field-label gform-field-label--type-inline">Heavy Duty Scooter</label>
</li>
</ul>
</div>
</li>
<li id="field_14_45"
class="gfield gfield--type-html gfield--input-type-html form-item heavy-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_45">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/HD-SCOOTER-MAXIMA-CHECKFRONT.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>The Stylish , high-performing scooter</p>
</li>
<li><i class="fa fa-check"></i>
<p>Weight Capacity: 500 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p>Batter Range: 11 Miles.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Scooter / Batter Weight: 150 / 65 Lbs</p>
</li>
</ul>
</li>
<li id="field_14_130"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio travel3-wrap gfield_price gfield_price_14_130 gfield_product_14_130 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_130"><label class="gfield_label gform-field-label">Transport Wheelchair</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_130">
<li class="gchoice gchoice_14_130_0">
<input name="input_130" type="radio" value="Transport Wheelchair|0" id="choice_14_130_0">
<label for="choice_14_130_0" id="label_14_130_0" class="gform-field-label gform-field-label--type-inline">Transport Wheelchair</label>
</li>
</ul>
</div>
</li>
<li id="field_14_46"
class="gfield gfield--type-html gfield--input-type-html form-item travel3-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_46">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2015/06/WRANGLER-II-SMALL.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Ultra Lightweight Transport Chair easily fits into a any Cab or any medium size car.</p>
</li>
<li><i class="fa fa-check"></i>
<p>With its attendant operated wheel looks</p>
</li>
<li><i class="fa fa-check"></i>
<p>Seat Width: 19 x 16 will accommodates someone up to 260 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p> Weight 19 Lbs with Legrest.</p>
</li>
</ul>
</li>
<li id="field_14_132"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio standard-wrap gfield_price gfield_price_14_132 gfield_product_14_132 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_132"><label class="gfield_label gform-field-label">Standard 4 Wheel Scooter</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_132">
<li class="gchoice gchoice_14_132_0">
<input name="input_132" type="radio" value="Standard 4 Wheel Scooter|0" id="choice_14_132_0">
<label for="choice_14_132_0" id="label_14_132_0" class="gform-field-label gform-field-label--type-inline">Standard 4 Wheel Scooter</label>
</li>
</ul>
</div>
</li>
<li id="field_14_47"
class="gfield gfield--type-html gfield--input-type-html form-item standard-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_47">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/STANDARD-SCOOTER-CHECKFRONT-2-2.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Transportable 4 Wheel Scooter</p>
</li>
<li><i class="fa fa-check"></i>
<p>4 Wheel Design Allows for Maximum Stability, 40 Inch Turning Radius with 325 Lbs Capacity.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Top Speed of 4.5 MPH and a Cruising range of 12 Miles.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Fully Disassemble to 4 Pieces in Matter of Seconds, and Can Easily Fit into the Trunk of an Car.</p>
</li>
</ul>
</li>
<li id="field_14_134"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio transport-wrap gfield_price gfield_price_14_134 gfield_product_14_134 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_134"><label class="gfield_label gform-field-label">Travel Powerchair</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_134">
<li class="gchoice gchoice_14_134_0">
<input name="input_134" type="radio" value="Travel Powerchair|0" id="choice_14_134_0">
<label for="choice_14_134_0" id="label_14_134_0" class="gform-field-label gform-field-label--type-inline">Travel Powerchair</label>
</li>
</ul>
</div>
</li>
<li id="field_14_48"
class="gfield gfield--type-html gfield--input-type-html form-item transport-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_48">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/TRAVEL-POWERCHAIR-PNG-SMALL.png" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>The Most Luxuries Powerchair, This Sporty Powerchair Delivers Superior Comfort all Day.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Weight Capacity of 325 Lbs, with seat size of 18 Inches.</p>
</li>
</ul>
</li>
<li id="field_14_270"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full pride-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_270">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>SELECT ONE MOBILITY SCOOTER (CLICK THE CIRCLE)</p>
</ul>
</li>
<li id="field_14_271"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full pride-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_271">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>SELECT ONE WHEELCHAIR (CLICK THE CIRCLE)</p>
</ul>
</li>
<li id="field_14_272"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full pride-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_272">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>SELECT ONE ROLLATOR (CLICK THE CIRCLE)</p>
</ul>
</li>
<li id="field_14_273"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full pride-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_273">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>SELECT ONE CONCENTRATOR (CLICK THE CIRCLE)</p>
</ul>
</li>
<li id="field_14_320"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full pride-wrap gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_320">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/1210584_alert_attention_caution_error_exclamation_icon-4.png" alt=""></ul>
<ul>
<p>SELECT ONE ITEM (CLICK THE CIRCLE)</p>
</ul>
</li>
<li id="field_14_49"
class="gfield gfield--type-html gfield--input-type-html question-mark gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_14_49">
<div class="protection-full-width">
<div class="close-video upitnik-close" id="stop"><i class="fa fa-times"></i></div>
<div class="protection-plan-img">
<img src="https://mexicomobility.com/wp-content/uploads/2015/05/PROTECTION-PLAN-COVERAGE.jpg" alt="">
</div>
</div><span>?</span>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-PREVIOUS-BUTTON-MINI.png" id="gform_previous_button_14_10"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="jQuery("#gform_target_page_number_14").val("1"); jQuery("#gform_14").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_14").val("1"); jQuery("#gform_14").trigger("submit",[true]); } "> <input type="image"
src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-NEXT-BUTTON-MINI.png" id="gform_next_button_14_10" class="gform_next_button gform-theme-button button gform_image_button" alt="Next Page"
onclick="jQuery("#gform_target_page_number_14").val("3"); jQuery("#gform_14").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_14").val("3"); jQuery("#gform_14").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_14_3" class="gform_page forma-3-strana" data-js="page-field-id-10" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_14_3" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_14_247"
class="gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_247"><label class="gfield_label gform-field-label" for="input_14_247">Add a Rollator/Walker?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_247" id="input_14_247" class="small gfield_select" aria-describedby="gfield_description_14_247" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_247">*Rolllator rental rates as an ADDON item are reduced compared with as a primary rental item.</div>
</li>
<li id="field_14_246"
class="gfield gfield--type-product gfield--input-type-select gfield--width-full gfield_price gfield_price_14_246 gfield_product_14_246 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_246"><label class="gfield_label gform-field-label" for="input_14_246">Choose a Rollator/Walker Type<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_246" id="input_14_246" class="small gfield_select" aria-describedby="gfield_description_14_246" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Rollator Lite|0">Rollator Lite</option>
<option value="Rollator Heavy Duty|0">Rollator Heavy Duty</option>
<option value="Rollator-Wheelchair Combo|0">Rollator-Wheelchair Combo</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_246">*Rolllator lite 260lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity</div>
</li>
<li id="field_14_252"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_left_half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_252">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2023/02/ROLLATOR-BANNER-2023-TRANS.png" alt=""></li>
</ul>
</li>
<li id="field_14_323"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_323">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/06/Warning-260-e1719160912837.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Rollator HD instead.</p>
</ul>
</li>
<li id="field_14_324"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_324">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/06/Warning-300-e1719160905937.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Rollator HD instead.</p>
</ul>
</li>
<li id="field_14_19" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_19"><label class="gfield_label gform-field-label" for="input_14_19">Deliver to<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_19" id="input_14_19" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Hotel">Hotel</option>
<option value="Home">Home</option>
</select></div>
</li>
<li id="field_14_41" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_41"><label class="gfield_label gform-field-label" for="input_14_41">Hotel name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_41" id="input_14_41" type="text" value="" class="medium" placeholder="Hilton" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_14_95" class="gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_95"><label class="gfield_label gform-field-label gfield_label_before_complex">Address to Deliver<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street ginput_container_address gform-grid-row" id="input_14_95">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_14_95_1_container">
<input type="text" name="input_95.1" id="input_14_95_1" value="" placeholder="Be Accurate" aria-required="true">
<label for="input_14_95_1" id="input_14_95_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><input type="hidden" class="gform_hidden" name="input_95.4" id="input_14_95_4" value=""><input type="hidden" class="gform_hidden" name="input_95.6" id="input_14_95_6" value="">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_14_176" class="gfield gfield--type-address gfield--input-type-address gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_176"><label class="gfield_label gform-field-label gfield_label_before_complex">Address to Deliver the CPAP Machine<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_state has_zip ginput_container_address gform-grid-row" id="input_14_176">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_14_176_1_container">
<input type="text" name="input_176.1" id="input_14_176_1" value="" aria-required="true">
<label for="input_14_176_1" id="input_14_176_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_14_176_4_container">
<input type="text" name="input_176.4" id="input_14_176_4" value="" aria-required="true">
<label for="input_14_176_4" id="input_14_176_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_14_176_5_container">
<input type="text" name="input_176.5" id="input_14_176_5" value="" aria-required="true">
<label for="input_14_176_5" id="input_14_176_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
</span><input type="hidden" class="gform_hidden" name="input_176.6" id="input_14_176_6" value="">
<div class="gf_clear gf_clear_complex"></div>
</div>
<div class="gfield_description" id="gfield_description_14_176">This Service is Limited to Mexico.</div>
</li>
<li id="field_14_42" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_42"><label class="gfield_label gform-field-label" for="input_14_42">Used a Scooter before?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_42" id="input_14_42" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
</li>
<li id="field_14_23" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_23"><label class="gfield_label gform-field-label" for="input_14_23">How did you find us?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_23" id="input_14_23" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select an option</option>
<option value="Trip advisor">Trip advisor</option>
<option value="Facebook Ad">Facebook Ad</option>
<option value="Google Ad">Google Ad</option>
<option value="Our Facebook Site">Our Facebook Site</option>
<option value="Web Search (Random)">Web Search (Random)</option>
<option value="Returning costumer">Returning costumer</option>
<option value="Concierge or Bell Boy Referral">Concierge or Bell Boy Referral</option>
<option value="Other costumer recommended">Other costumer recommended</option>
</select></div>
</li>
<li id="field_14_137" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_137"><label class="gfield_label gform-field-label" for="input_14_137">Any special Need?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_137" id="input_14_137" class="small gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
</li>
<li id="field_14_22" class="gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_22"><label class="gfield_label gform-field-label" for="input_14_22">Indicate any special need or concern.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_22" id="input_14_22" class="textarea small" placeholder="Enter" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_14_119" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_119"><label class="gfield_label gform-field-label" for="input_14_119">I want to:<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_119" id="input_14_119" class="small gfield_select" aria-describedby="gfield_description_14_119" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Pay My Reservation Now!">Pay My Reservation Now!</option>
<option value="Pay Later (Send me a Quote by E - Mail)">Pay Later (Send me a Quote by E - Mail)</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_119">Rental Price is Shown Next Page When "Pay My Reservation Now!" is Selected. Usually 20% less When Paid Thru Our Website</div>
</li>
<li id="field_14_149" class="gfield gfield--type-select gfield--input-type-select gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_149"><label class="gfield_label gform-field-label" for="input_14_149">Pay With:<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_149" id="input_14_149" class="small gfield_select" aria-describedby="gfield_description_14_149" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Credit / Debit Card">Credit / Debit Card</option>
<option value="Pay Pal">Pay Pal</option>
</select></div>
<div class="gfield_description" id="gfield_description_14_149">Choose Payment Method</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-PREVIOUS-BUTTON-MINI.png" id="gform_previous_button_14_24"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="jQuery("#gform_target_page_number_14").val("2"); jQuery("#gform_14").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_14").val("2"); jQuery("#gform_14").trigger("submit",[true]); } "> <input type="image"
src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-NEXT-BUTTON-MINI.png" id="gform_next_button_14_24" class="gform_next_button gform-theme-button button gform_image_button" alt="Next Page"
onclick="jQuery("#gform_target_page_number_14").val("4"); jQuery("#gform_14").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_14").val("4"); jQuery("#gform_14").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_14_4" class="gform_page forma-4-strana" data-js="page-field-id-24" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_14_4" class="gform_fields top_label form_sublabel_below description_below validation_below">
<li id="field_14_178" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_178"><label class="gfield_label gform-field-label gfield_label_before_complex">Renter Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_14_178">
<span id="input_14_178_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_178.3" id="input_14_178_3" value="" aria-required="true" placeholder="John">
<label for="input_14_178_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_14_178_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_178.6" id="input_14_178_6" value="" aria-required="true" placeholder="Smith">
<label for="input_14_178_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</li>
<li id="field_14_64" class="gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_64"><label class="gfield_label gform-field-label" for="input_14_64">Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_64" id="input_14_64" type="tel" value="" class="small" placeholder="Mobile Number" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_14_64"></div>
<div class="gfield_description" id="gfield_description_14_64">(Country code + Phone number)</div>
</li>
<li id="field_14_38" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_38"><label class="gfield_label gform-field-label gfield_label_before_complex">Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container_email gform-grid-row" id="input_14_38_container">
<span id="input_14_38_1_container" class="ginput_left gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_38" id="input_14_38" value="" aria-required="true" aria-invalid="false">
<label for="input_14_38" class="gform-field-label gform-field-label--type-sub ">Enter Email</label>
</span>
<span id="input_14_38_2_container" class="ginput_right gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_38_2" id="input_14_38_2" value="" aria-required="true" aria-invalid="false">
<label for="input_14_38_2" class="gform-field-label gform-field-label--type-sub ">Confirm Email</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_14_54" class="gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_54"><label class="gfield_label gform-field-label" for="input_14_54">Country<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_54" id="input_14_54" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Congo, Republic of the">Congo, Republic of the</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Norway">Norway</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia and Montenegro">Serbia and Montenegro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Sudan, South">Sudan, South</option>
<option value="Suriname">Suriname</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States" selected="selected">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select></div>
</li>
<li id="field_14_311" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_311">
<h2 class="gsection_title">Your Booking Breakdown</h2>
</li>
<li id="field_14_275"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_275 gfield_product_14_275 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_275"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_275_1"><span class="gform-field-label gfield_label_product">CPAP Mask</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_275.1" value="CPAP Mask" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_275">$175.00</span>
<input type="hidden" name="input_275.2" id="ginput_base_price_14_275" class="gform_hidden" value="$175.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_275.3" value="" id="input_14_275_1" class="ginput_quantity" size="10" min="0" aria-label="Quantity CPAP Mask"
aria-describedby="gfield_description_14_275">
</div>
<div class="gfield_description" id="gfield_description_14_275">**Indicate Quantity</div>
</li>
<li id="field_14_276"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_276 gfield_product_14_276 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_276"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_276_1"><span class="gform-field-label gfield_label_product">CPAP Tubing</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_276.1" value="CPAP Tubing" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_276">$75.00</span>
<input type="hidden" name="input_276.2" id="ginput_base_price_14_276" class="gform_hidden" value="$75.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_276.3" value="" id="input_14_276_1" class="ginput_quantity" size="10" min="0" aria-label="Quantity CPAP Tubing"
aria-describedby="gfield_description_14_276">
</div>
<div class="gfield_description" id="gfield_description_14_276">**Indicate Quantity</div>
</li>
<li id="field_14_277"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_277 gfield_product_14_277 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_277"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_277_1"><span class="gform-field-label gfield_label_product">CPAP Mask + Tubing</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_277.1" value="CPAP Mask + Tubing" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_277">$250.00</span>
<input type="hidden" name="input_277.2" id="ginput_base_price_14_277" class="gform_hidden" value="$250.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_277.3" value="" id="input_14_277_1" class="ginput_quantity" size="10" min="0"
aria-label="Quantity CPAP Mask + Tubing" aria-describedby="gfield_description_14_277">
</div>
<div class="gfield_description" id="gfield_description_14_277">**Indicate Quantity</div>
</li>
<li id="field_14_278"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_278 gfield_product_14_278 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_278"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_278_1"><span class="gform-field-label gfield_label_product">CPAP Mask</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_278.1" value="CPAP Mask" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_278">$175.00</span>
<input type="hidden" name="input_278.2" id="ginput_base_price_14_278" class="gform_hidden" value="$175.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_278.3" value="" id="input_14_278_1" class="ginput_quantity" size="10" min="0" aria-label="Quantity CPAP Mask"
aria-describedby="gfield_description_14_278">
</div>
<div class="gfield_description" id="gfield_description_14_278">**Indicate Quantity</div>
</li>
<li id="field_14_279"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_279 gfield_product_14_279 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_279"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_279_1"><span class="gform-field-label gfield_label_product">CPAP Tubing</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_279.1" value="CPAP Tubing" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_279">$0.00</span>
<input type="hidden" name="input_279.2" id="ginput_base_price_14_279" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_279.3" value="" id="input_14_279_1" class="ginput_quantity" size="10" min="0" aria-label="Quantity CPAP Tubing"
aria-describedby="gfield_description_14_279">
</div>
<div class="gfield_description" id="gfield_description_14_279">**Indicate Quantity</div>
</li>
<li id="field_14_281"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_281 gfield_product_14_281 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_281"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_281_1"><span class="gfield_label_product gform-field-label">Everflo Stationary Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_281.1" value="Everflo Stationary Oxygen Concentrator" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_281">$0.00</span>
<input type="hidden" name="input_281.2" id="ginput_base_price_14_281" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_281.3" value="" id="input_14_281_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_281">
</div>
<div class="gfield_description" id="gfield_description_14_281">**Indicate Quantity</div>
</li>
<li id="field_14_283"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_283 gfield_product_14_283 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_283"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_283_1"><span class="gfield_label_product gform-field-label">Everflo Stationary Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_283.1" value="Everflo Stationary Oxygen Concentrator" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_283">$0.00</span>
<input type="hidden" name="input_283.2" id="ginput_base_price_14_283" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_283.3" value="" id="input_14_283_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_283">
</div>
<div class="gfield_description" id="gfield_description_14_283">**Indicate Quantity</div>
</li>
<li id="field_14_280"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_280 gfield_product_14_280 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_280"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_280_1"><span class="gfield_label_product gform-field-label">Rollator Lite</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_280.1" value="Rollator Lite" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_280">$0.00</span>
<input type="hidden" name="input_280.2" id="ginput_base_price_14_280" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_280.3" value="" id="input_14_280_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_280">
</div>
<div class="gfield_description" id="gfield_description_14_280">**Indicate Quantity</div>
</li>
<li id="field_14_282"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_282 gfield_product_14_282 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_282"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_282_1"><span class="gfield_label_product gform-field-label">Rollator Heavy Duty</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_282.1" value="Rollator Heavy Duty" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_282">$0.00</span>
<input type="hidden" name="input_282.2" id="ginput_base_price_14_282" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_282.3" value="" id="input_14_282_1" class="ginput_quantity" size="10" min="0">
</div>
</li>
<li id="field_14_284"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_284 gfield_product_14_284 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_284"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_284_1"><span class="gfield_label_product gform-field-label">Rollator-Wheelchair Combo</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_284.1" value="Rollator-Wheelchair Combo" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_284">$0.00</span>
<input type="hidden" name="input_284.2" id="ginput_base_price_14_284" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_284.3" value="" id="input_14_284_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_284">
</div>
<div class="gfield_description" id="gfield_description_14_284">**Indicate Quantity</div>
</li>
<li id="field_14_285"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_285 gfield_product_14_285 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_285"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_285_1"><span class="gfield_label_product gform-field-label">STAND-N-RIDE SCOOTER</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_285.1" value="STAND-N-RIDE SCOOTER" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_285">$0.00</span>
<input type="hidden" name="input_285.2" id="ginput_base_price_14_285" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_285.3" value="" id="input_14_285_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_285">
</div>
<div class="gfield_description" id="gfield_description_14_285">**Indicate Quantity</div>
</li>
<li id="field_14_286"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_286 gfield_product_14_286 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_286"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_286_1"><span class="gfield_label_product gform-field-label">CPAP Machine</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_286.1" value="CPAP Machine" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_286">$0.00</span>
<input type="hidden" name="input_286.2" id="ginput_base_price_14_286" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_286.3" value="" id="input_14_286_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_286">
</div>
<div class="gfield_description" id="gfield_description_14_286">**Indicate Quantity</div>
</li>
<li id="field_14_287"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_287 gfield_product_14_287 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_287"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_287_1"><span class="gfield_label_product gform-field-label">CPAP Machine</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_287.1" value="CPAP Machine" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_287">$0.00</span>
<input type="hidden" name="input_287.2" id="ginput_base_price_14_287" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_287.3" value="" id="input_14_287_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_287">
</div>
<div class="gfield_description" id="gfield_description_14_287">**Indicate Quantity</div>
</li>
<li id="field_14_288"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_288 gfield_product_14_288 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_288"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_288_1"><span class="gfield_label_product gform-field-label">Portable Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_288.1" value="Portable Oxygen Concentrator" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_288">$0.00</span>
<input type="hidden" name="input_288.2" id="ginput_base_price_14_288" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_288.3" value="" id="input_14_288_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_288">
</div>
<div class="gfield_description" id="gfield_description_14_288">**Indicate Quantity</div>
</li>
<li id="field_14_289"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_289 gfield_product_14_289 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_289"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_289_1"><span class="gfield_label_product gform-field-label">Portable Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_289.1" value="Portable Oxygen Concentrator" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_289">$0.00</span>
<input type="hidden" name="input_289.2" id="ginput_base_price_14_289" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_289.3" value="" id="input_14_289_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_289">
</div>
<div class="gfield_description" id="gfield_description_14_289">**Indicate Quantity</div>
</li>
<li id="field_14_291"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_291 gfield_product_14_291 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_291"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_291_1"><span class="gfield_label_product gform-field-label">Standard Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_291.1" value="Standard Wheelchair" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_291">$0.00</span>
<input type="hidden" name="input_291.2" id="ginput_base_price_14_291" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_291.3" value="" id="input_14_291_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_291">
</div>
<div class="gfield_description" id="gfield_description_14_291">**Indicate Quantity</div>
</li>
<li id="field_14_292"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_292 gfield_product_14_292 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_292"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_292_1"><span class="gfield_label_product gform-field-label">HD Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_292.1" value="HD Wheelchair" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_292">$0.00</span>
<input type="hidden" name="input_292.2" id="ginput_base_price_14_292" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_292.3" value="" id="input_14_292_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_292">
</div>
<div class="gfield_description" id="gfield_description_14_292">**Indicate Quantity</div>
</li>
<li id="field_14_293"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_293 gfield_product_14_293 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_293"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_293_1"><span class="gfield_label_product gform-field-label">Travel 4 Wheels Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_293.1" value="Travel 4 Wheels Scooter" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_293">$0.00</span>
<input type="hidden" name="input_293.2" id="ginput_base_price_14_293" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_293.3" value="" id="input_14_293_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_293">
</div>
<div class="gfield_description" id="gfield_description_14_293">**Indicate Quantity</div>
</li>
<li id="field_14_294"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_294 gfield_product_14_294 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_294"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_294_1"><span class="gfield_label_product gform-field-label">Heavy Duty Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_294.1" value="Heavy Duty Scooter" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_294">$0.00</span>
<input type="hidden" name="input_294.2" id="ginput_base_price_14_294" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_294.3" value="" id="input_14_294_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_294">
</div>
<div class="gfield_description" id="gfield_description_14_294">**Indicate Quantity</div>
</li>
<li id="field_14_295"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_295 gfield_product_14_295 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_295"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_295_1"><span class="gfield_label_product gform-field-label">Transport Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_295.1" value="Transport Wheelchair" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_295">$0.00</span>
<input type="hidden" name="input_295.2" id="ginput_base_price_14_295" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_295.3" value="" id="input_14_295_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_295">
</div>
<div class="gfield_description" id="gfield_description_14_295">**Indicate Quantity</div>
</li>
<li id="field_14_296"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_296 gfield_product_14_296 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_296"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_296_1"><span class="gfield_label_product gform-field-label">Standard 4 Wheel Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_296.1" value="Standard 4 Wheel Scooter" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_296">$0.00</span>
<input type="hidden" name="input_296.2" id="ginput_base_price_14_296" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_296.3" value="" id="input_14_296_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_296">
</div>
<div class="gfield_description" id="gfield_description_14_296">**Indicate Quantity</div>
</li>
<li id="field_14_297"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_297 gfield_product_14_297 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_297"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_297_1"><span class="gfield_label_product gform-field-label">Travel Powerchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_297.1" value="Travel Powerchair" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_297">$0.00</span>
<input type="hidden" name="input_297.2" id="ginput_base_price_14_297" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_297.3" value="" id="input_14_297_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_297">
</div>
<div class="gfield_description" id="gfield_description_14_297">**Indicate Quantity</div>
</li>
<li id="field_14_298"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_298 gfield_product_14_298 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_298"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_298_1"><span class="gfield_label_product gform-field-label">Rollator Lite</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_298.1" value="Rollator Lite" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_298">$0.00</span>
<input type="hidden" name="input_298.2" id="ginput_base_price_14_298" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_298.3" value="" id="input_14_298_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_298">
</div>
<div class="gfield_description" id="gfield_description_14_298">**Indicate Quantity</div>
</li>
<li id="field_14_299"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_299 gfield_product_14_299 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_299"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_299_1"><span class="gfield_label_product gform-field-label">Rollator Heavy Duty</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_299.1" value="Rollator Heavy Duty" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_299">$0.00</span>
<input type="hidden" name="input_299.2" id="ginput_base_price_14_299" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_299.3" value="" id="input_14_299_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_299">
</div>
<div class="gfield_description" id="gfield_description_14_299">**Indicate Quantity</div>
</li>
<li id="field_14_300"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_300 gfield_product_14_300 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_300"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_300_1"><span class="gfield_label_product gform-field-label">Rollator-Wheelchair Combo</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_300.1" value="Rollator-Wheelchair Combo" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_300">$0.00</span>
<input type="hidden" name="input_300.2" id="ginput_base_price_14_300" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_300.3" value="" id="input_14_300_1" class="ginput_quantity" size="10" min="0"
aria-describedby="gfield_description_14_300">
</div>
<div class="gfield_description" id="gfield_description_14_300">**Indicate Quantity</div>
</li>
<li id="field_14_301"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_301 gfield_product_14_301 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_301"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_301_1">Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_301.1" value="Wheelchair Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_301">$0.00</span>
<input type="hidden" name="input_301.2" id="ginput_base_price_14_301" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_301.3" value="1" class="ginput_quantity_14_301 gform_hidden">
</div>
</li>
<li id="field_14_302"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_302 gfield_product_14_302 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_302"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_302_1">Scooter Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_302.1" value="Scooter Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_302">$0.00</span>
<input type="hidden" name="input_302.2" id="ginput_base_price_14_302" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_302.3" value="1" class="ginput_quantity_14_302 gform_hidden">
</div>
</li>
<li id="field_14_303"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_303 gfield_product_14_303 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_303"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_303_1">Rollator Delivery & Pick up Fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_303.1" value="Rollator Delivery & Pick up Fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_303">$0.00</span>
<input type="hidden" name="input_303.2" id="ginput_base_price_14_303" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_303.3" value="1" class="ginput_quantity_14_303 gform_hidden">
</div>
</li>
<li id="field_14_304"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_304 gfield_product_14_304 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_304"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_304_1">Rollator Delivery & Pick up Fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_304.1" value="Rollator Delivery & Pick up Fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_304">$0.00</span>
<input type="hidden" name="input_304.2" id="ginput_base_price_14_304" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_304.3" value="1" class="ginput_quantity_14_304 gform_hidden">
</div>
</li>
<li id="field_14_305"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_305 gfield_product_14_305 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_305"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_305_1">Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_305.1" value="Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_305">$0.00</span>
<input type="hidden" name="input_305.2" id="ginput_base_price_14_305" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_305.3" value="1" class="ginput_quantity_14_305 gform_hidden">
</div>
</li>
<li id="field_14_306"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_306 gfield_product_14_306 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_306"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_306_1">Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_306.1" value="Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_306">$0.00</span>
<input type="hidden" name="input_306.2" id="ginput_base_price_14_306" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_306.3" value="1" class="ginput_quantity_14_306 gform_hidden">
</div>
</li>
<li id="field_14_322"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_322 gfield_product_14_322 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_322"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_322_1">Portable Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_322.1" value="Portable Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_322">$0.00</span>
<input type="hidden" name="input_322.2" id="ginput_base_price_14_322" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_322.3" value="1" class="ginput_quantity_14_322 gform_hidden">
</div>
</li>
<li id="field_14_307"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_307 gfield_product_14_307 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_307"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_307_1">CPAP Machine Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_307.1" value="CPAP Machine Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_307">$0.00</span>
<input type="hidden" name="input_307.2" id="ginput_base_price_14_307" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_307.3" value="1" class="ginput_quantity_14_307 gform_hidden">
</div>
</li>
<li id="field_14_309"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_309 gfield_product_14_309 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_309"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_309_1">CPAP Machine Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_309.1" value="CPAP Machine Delivery & Pick up fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_309">$0.00</span>
<input type="hidden" name="input_309.2" id="ginput_base_price_14_309" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_309.3" value="1" class="ginput_quantity_14_309 gform_hidden">
</div>
</li>
<li id="field_14_310"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_14_310 gfield_product_14_310 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_310"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_310_1">Stand N Ride Delivery & Pick up Fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_310.1" value="Stand N Ride Delivery & Pick up Fee" class="gform_hidden">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_14_310">$0.00</span>
<input type="hidden" name="input_310.2" id="ginput_base_price_14_310" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_310.3" value="1" class="ginput_quantity_14_310 gform_hidden">
</div>
</li>
<li id="field_14_308"
class="gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_14_308 gfield_product_14_308 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_308"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_14_308_1">Supplies Delivery Fee<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_singleproduct">
<input type="hidden" name="input_308.1" value="Supplies Delivery Fee" class="gform_hidden">
<label for="ginput_base_price_14_308" class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</label>
<input type="text" readonly="" class="ginput_product_price gform-text-input-reset" name="input_308.2" id="ginput_base_price_14_308" value="$25.00" aria-label="Supplies Delivery Fee Price">
<input type="hidden" name="input_308.3" value="1" class="ginput_quantity_14_308 gform_hidden">
</div>
</li>
<li id="field_14_217"
class="gfield gfield--type-total gfield--input-type-total gfield_price gfield_price_14_ gfield_total gfield_total_14_ field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
aria-atomic="true" aria-live="polite" data-js-reload="field_14_217"><label class="gfield_label gform-field-label" for="input_14_217">Rental Total</label>
<div class="ginput_container ginput_container_total">
<span class="ginput_total ginput_total_14">$0.00</span>
<input type="hidden" name="input_217" id="input_14_217" class="gform_hidden">
</div>
<div class="gfield_description" id="gfield_description_14_217">Your Rental Total</div>
</li>
<li id="field_14_312" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_312">
<h2 class="gsection_title">**Indicate Items Quantity</h2>
</li>
<li id="field_14_216"
class="gfield gfield--type-stripe_creditcard gfield--input-type-stripe_creditcard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-payment-element"
data-js-reload="field_14_216"><label class="gfield_label gfield_label_before_complex gform-field-label" for="input_14_216_1">Credit / Debit Card<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row" id="input_14_216">
<div class="ginput_full gform-grid-col" id="input_14_216_1_container" data-payment-element="true">
<div id="input_14_216_1" class="StripeElement--payment-element"></div>
</div><!-- .ginput_full -->
</div><!-- .ginput_container -->
<style type="text/css">
:root {
--link-login-string: "Link login"
}
</style>
</li>
<li id="field_14_321"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_321">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/PAYPAL-BANNER-TRANS-e1720200552857.png" alt=""></ul>
</li>
<li id="field_14_314" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_314">
<h2 class="gsection_title"></h2>
</li>
<li id="field_14_317"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_317"><label class="gfield_label gform-field-label">Read Terms & Conditions Before Completing Reservation!<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_14_317">
<li class="gchoice gchoice_14_317_0">
<input name="input_317" type="radio" value="I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy" id="choice_14_317_0">
<label for="choice_14_317_0" id="label_14_317_0" class="gform-field-label gform-field-label--type-inline">I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_14_317">Click Over the text "TERMS AND CONDITIONS" to Read!</div>
</li>
<li id="field_14_315"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_315">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/07/CANCELLATION-POLICY-COVID-2020-21-e1720066773438.png" alt=""></ul>
</li>
<li id="field_14_37"
class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_14_37">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label gfield_label_before_complex">Read Terms & Conditions Before Completing
Reservation!<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_14_37">
<li class="gchoice gchoice_14_37_1">
<input class="gfield-choice-input" name="input_37.1" type="checkbox" value="I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy" id="choice_14_37_1"
aria-describedby="gfield_description_14_37">
<label for="choice_14_37_1" id="label_14_37_1" class="gform-field-label gform-field-label--type-inline">I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_14_37">Click Over the text to Read Our Cancellation Policy!</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="image" src="https://mexicomobility.com/wp-content/uploads/2015/02/DISABLED-PREVIOUS-BUTTON-MINI.png" id="gform_previous_button_14"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} jQuery("#gform_14").trigger("submit",[true]); }">
<input type="submit" id="gform_submit_button_14" class="gform_button button" value="Place Reservation"
onclick="if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} jQuery("#gform_14").trigger("submit",[true]); }">
<input type="hidden" name="gform_ajax" value="form_id=14&title=1&description=1&tabindex=0&theme=legacy">
<input type="hidden" class="gform_hidden" name="is_submit_14" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="14">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_14"
value="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">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_14" id="gform_target_page_number_14" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_14" id="gform_source_page_number_14" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
</form>POST /#gf_15
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_15" id="gform_15" action="/#gf_15" data-formid="15" novalidate="">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_page_15_1" class="gform_page forma-1-strana" data-js="page-field-id-1">
<div class="gform_page_fields">
<div id="gform_fields_15" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_15_270" class="gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_270">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label" for="input_15_270">Number of Days</label>
<div class="ginput_container ginput_container_number"><input name="input_270" id="input_15_270" type="text" step="any" value="" class="small" readonly="readonly" aria-invalid="false"></div>
</div>
<div id="field_15_343"
class="gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_343"><label class="gfield_label gform-field-label" for="input_15_343">Choose a Different Type of Equipment<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_343" id="input_15_343" class="medium gfield_select" aria-describedby="gfield_description_15_343" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Mobility Scooters" selected="selected">Mobility Scooters</option>
<option value="Manual or Electric Wheelchairs">Manual or Electric Wheelchairs</option>
<option value="Rollators/Walkers">Rollators/Walkers</option>
<option value="Oxygen Concentrator / CPAP">Oxygen Concentrator / CPAP</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_343">Choose the equipment type you need.</div>
</div>
<div id="field_15_428"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_428">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/09/EQUIPMENT-TYPES-TRANS.png" alt=""></ul>
<ul>
</ul>
</div>
<div id="field_15_422" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_422">
<h3 class="gsection_title">Start by Picking Your Rental Dates</h3>
<div class="gsection_description" id="gfield_description_15_422">Minimum Rental Length is 3 Calendar days.</div>
</div>
<div id="field_15_92"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-custom-icon gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_92"><label class="gfield_label gform-field-label" for="input_15_92">Delivery Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_92" id="input_15_92" type="text" value="10/11/2024" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy"
aria-describedby="input_15_92_date_format gfield_description_15_92" aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://mexicomobility.mx/wp-content/uploads/2023/02/Calendar-icon-2023.png"
alt="Select date" title="Select date">
<span id="input_15_92_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_15_92" class="gform_hidden" value="https://mexicomobility.mx/wp-content/uploads/2023/02/Calendar-icon-2023.png">
<div class="gfield_description" id="gfield_description_15_92">Date when Rental Begins. *Minimum rental is 3 Calendar days*</div>
</div>
<div id="field_15_2"
class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-custom-icon gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_2"><label class="gfield_label gform-field-label" for="input_15_2">Return Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_2" id="input_15_2" type="text" value="10/11/2024" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy"
aria-describedby="input_15_2_date_format gfield_description_15_2" aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://mexicomobility.mx/wp-content/uploads/2023/02/Calendar-icon-2023.png"
alt="Select date" title="Select date">
<span id="input_15_2_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_15_2" class="gform_hidden" value="https://mexicomobility.mx/wp-content/uploads/2023/02/Calendar-icon-2023.png">
<div class="gfield_description" id="gfield_description_15_2">Date when Rental Ends. *Minimum rental is 3 Calendar days*</div>
</div>
<fieldset id="field_15_296"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible"
data-js-reload="field_15_296">
<legend class="gfield_label gform-field-label">Select your Scooter<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="gfield_description" id="gfield_description_15_296">***Click the scooter Button to compare price and see a picture</div>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_15_296">
<div class="gchoice gchoice_15_296_0">
<input class="gfield-choice-input" name="input_296" type="radio" value="Travel Scooter" id="choice_15_296_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_15_296">
<label for="choice_15_296_0" id="label_15_296_0" class="gform-field-label gform-field-label--type-inline">Travel Scooter</label>
</div>
<div class="gchoice gchoice_15_296_1">
<input class="gfield-choice-input" name="input_296" type="radio" value="Standard Scooter" id="choice_15_296_1" onchange="gformToggleRadioOther( this )">
<label for="choice_15_296_1" id="label_15_296_1" class="gform-field-label gform-field-label--type-inline">Standard Scooter</label>
</div>
<div class="gchoice gchoice_15_296_2">
<input class="gfield-choice-input" name="input_296" type="radio" value="Heavy Duty Scooter" id="choice_15_296_2" onchange="gformToggleRadioOther( this )">
<label for="choice_15_296_2" id="label_15_296_2" class="gform-field-label gform-field-label--type-inline">Heavy Duty Scooter</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_303"
class="gfield gfield--type-number gfield--input-type-number gfield--width-third gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_303"><label class="gfield_label gform-field-label" for="input_15_303">Scooter User's Weight in Lbs<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_303" id="input_15_303" type="number" step="any" value="" class="small" placeholder="0" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_303"></div>
<div class="gfield_description" id="gfield_description_15_303">Check weight capacity limits. (KgsX2.2=Lbs)</div>
</div>
<div id="field_15_431" class="gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_431">
<ul><img src="https://mexicomobility.com/wp-content/uploads/2024/06/1210584_alert_attention_caution_error_exclamation_icon-3-1-e1719876487964.png" alt=""></ul>
<ul>
<p> !!!!!!Minimum Rental Length is 3 Calendar days. Adjust dates to Enable "Next Button"</p>
</ul>
</div>
<div id="field_15_279"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_279">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/SCOOTERS-BANNER-TRANS-e1717880569276.png" alt=""></ul>
</div>
<div id="field_15_432" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_432">
<h3 class="gsection_title">3 Calendar days Rental Sample (Minimum Length).</h3>
</div>
<div id="field_15_272"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gf_right_half gfield--width-half gfield_price gfield_price_15_272 gfield_product_15_272 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_272"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_272_1">Travel 4 Wheels Scooter<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_272.1" value="Travel 4 Wheels Scooter" class="gform_hidden">
<div id="ginput_product_price_15_272" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_272">$0.00</span>
</div>
<input type="hidden" name="input_272.2" id="ginput_base_price_15_272" class="gform_hidden" value="$0.00">
</div>
<div class="gfield_description" id="gfield_description_15_272">*Price per day </div>
</div>
<div id="field_15_425"
class="gfield gfield--type-quantity gfield--input-type-number gfield--width-third gfield_price gfield_price_15_272 gfield_quantity gfield_quantity_15_272 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_425"><label class="gfield_label gform-field-label" for="input_15_425">Travel Scooter Qty<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_425" id="input_15_425" type="number" step="any" min="1" max="4" value="1" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_15_425 gfield_description_15_425">
<div class="gfield_description instruction " id="gfield_instruction_15_425">Please enter a number from <strong>1</strong> to <strong>4</strong>.</div>
</div>
<div class="gfield_description" id="gfield_description_15_425">**Indicate Quantity</div>
</div>
<div id="field_15_273"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_273 gfield_product_15_273 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_273"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_273_1">Travel Scooter Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_273.1" value="Travel Scooter Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_273" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_273">$0.00</span>
</div>
<input type="hidden" name="input_273.2" id="ginput_base_price_15_273" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_273.3" value="1" class="ginput_quantity_15_273 gform_hidden">
</div>
</div>
<div id="field_15_284"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gf_right_half gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_284">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/TRAVEL-e1717726468281.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_332"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_332"><label class="gfield_label gform-field-label" for="input_15_332">Rental Total - Travel Scooter<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_332" id="input_15_332" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_332"></div>
<div class="gfield_description" id="gfield_description_15_332">**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_421" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_421">
<h3 class="gsection_title">Your Total Breakdown - Scooter Rental</h3>
<div class="gsection_description" id="gfield_description_15_421">*Select Quantity to Calculate your Total **Rental total include Taxes and Delivery/Pickup</div>
</div>
<div id="field_15_339"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gf_right_half gfield--width-half gfield_price gfield_price_15_339 gfield_product_15_339 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_339"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_339_1"><span class="gfield_label_product gform-field-label">Travel 4 Wheels Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_339.1" value="Travel 4 Wheels Scooter" class="gform_hidden">
<div id="ginput_product_price_15_339" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_339">$0.00</span>
</div>
<input type="hidden" name="input_339.2" id="ginput_base_price_15_339" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_339.3" value="" id="input_15_339_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_339 gfield_description_15_339">
</div>
<div class="gfield_description" id="gfield_description_15_339">*Indicate Quantity</div>
</div>
<div id="field_15_340"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_340 gfield_product_15_340 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_340"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_340_1">Travel Scooter Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_340.1" value="Travel Scooter Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_340" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_340">$0.00</span>
</div>
<input type="hidden" name="input_340.2" id="ginput_base_price_15_340" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_340.3" value="1" class="ginput_quantity_15_340 gform_hidden">
</div>
</div>
<div id="field_15_341"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gf_right_half gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_341">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/TRAVEL-e1717726468281.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_342"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_342"><label class="gfield_label gform-field-label" for="input_15_342">Rental Total - Travel Scooter<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_342" id="input_15_342" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_342"></div>
<div class="gfield_description" id="gfield_description_15_342">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_287"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_287">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-260-e1717727666387.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Standard Scooter instead.</p>
</ul>
</div>
<div id="field_15_275"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gf_right_half gfield--width-half gfield_price gfield_price_15_275 gfield_product_15_275 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_275"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_275_1"><span class="gfield_label_product gform-field-label">Standard 4 Wheel Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_275.1" value="Standard 4 Wheel Scooter" class="gform_hidden">
<div id="ginput_product_price_15_275" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_275">$0.00</span>
</div>
<input type="hidden" name="input_275.2" id="ginput_base_price_15_275" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_275.3" value="" id="input_15_275_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_275 gfield_description_15_275">
</div>
<div class="gfield_description" id="gfield_description_15_275">**Indicate Quantity</div>
</div>
<div id="field_15_311"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_311 gfield_product_15_311 gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_311"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_311_1">Standard Scooter Delivery & Pick up fee</label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_311.1" value="Standard Scooter Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_311" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_311">$0.00</span>
</div>
<input type="hidden" name="input_311.2" id="ginput_base_price_15_311" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_311.3" value="1" class="ginput_quantity_15_311 gform_hidden">
</div>
</div>
<div id="field_15_47"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gf_right_half gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_47">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STANDARD-e1717726489845.png" alt=""></ul>
<ul>
<p>4 Wheel Scooter - 325Lbs Lbs Weight Capacity - Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_333"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_333"><label class="gfield_label gform-field-label" for="input_15_333">Rental Total - Standard Scooter<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_333" id="input_15_333" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_333"></div>
<div class="gfield_description" id="gfield_description_15_333">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_304"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_304">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-325-e1717727854752.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.</p>
</ul>
</div>
<div id="field_15_274"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gf_right_half gfield--width-half gfield_price gfield_price_15_274 gfield_product_15_274 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_274"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_274_1"><span class="gfield_label_product gform-field-label">Heavy Duty Scooter</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_274.1" value="Heavy Duty Scooter" class="gform_hidden">
<div id="ginput_product_price_15_274" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_274">$0.00</span>
</div>
<input type="hidden" name="input_274.2" id="ginput_base_price_15_274" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_274.3" value="" id="input_15_274_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_274 gfield_description_15_274">
</div>
<div class="gfield_description" id="gfield_description_15_274">**Indicate Quantity</div>
</div>
<div id="field_15_310"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_310 gfield_product_15_310 gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_310"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_310_1">HD Scooter Delivery & Pick up fee</label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_310.1" value="HD Scooter Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_310" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_310">$0.00</span>
</div>
<input type="hidden" name="input_310.2" id="ginput_base_price_15_310" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_310.3" value="1" class="ginput_quantity_15_310 gform_hidden">
</div>
</div>
<div id="field_15_45"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gf_right_half gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_45">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/HD-e1717726480586.png" alt=""></ul>
<ul>
<p>Stylish and high-performing scooter. Weight Capacity: 500 Lbs. Batter Range: 11 Miles. Scooter total weight 150.</p>
</ul>
</div>
<div id="field_15_334"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_334"><label class="gfield_label gform-field-label" for="input_15_334">Rental Total - HD Scooter<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_334" id="input_15_334" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_334"></div>
<div class="gfield_description" id="gfield_description_15_334">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_344" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_344">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">Wheelchairs</h3>
</div>
<div id="field_15_346"
class="gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_15_346 gfield_product_15_346 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_346"><label class="gfield_label gform-field-label" for="input_15_346">Choose a Wheelchair Type<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_346" id="input_15_346" class="small gfield_select" aria-describedby="gfield_description_15_346" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Choose</option>
<option value="Standard Wheelchair|0">Standard Wheelchair</option>
<option value="Transport Wheelchair|0">Transport Wheelchair</option>
<option value="Heavy Duty Wheelchair|0">Heavy Duty Wheelchair</option>
<option value="Electric (Travel Powerchair)|0">Electric (Travel Powerchair)</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_346">Weight Capacity *Standard Wheelchair 300lbs. ** Heavy Duty Wheelchair 500lbs. ***Electric Wheelchair 250lbs. ****Transport Wheelchair 250 lbs</div>
</div>
<div id="field_15_347"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_347"><label class="gfield_label gform-field-label" for="input_15_347">Wheelchair User's Weight in Lbs<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_347" id="input_15_347" type="number" step="any" value="" class="small" placeholder="0" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_347"></div>
<div class="gfield_description" id="gfield_description_15_347">Check weight capacity limits. (KgsX2.2=Lbs)</div>
</div>
<div id="field_15_348"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_348">
<ul>
<li><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/WHEELCHAIR-BANNER-TRANS-e1718162121356.png" alt=""></li>
</ul>
</div>
<div id="field_15_350"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_350 gfield_product_15_350 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_350"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_350_1">Standard Wheelchair<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_350.1" value="Standard Wheelchair" class="gform_hidden">
<div id="ginput_product_price_15_350" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_350">$0.00</span>
</div>
<input type="hidden" name="input_350.2" id="ginput_base_price_15_350" class="gform_hidden" value="$0.00">
</div>
<div class="gfield_description" id="gfield_description_15_350">*Price Per Day</div>
</div>
<div id="field_15_427"
class="gfield gfield--type-quantity gfield--input-type-number gfield--width-third gfield_price gfield_price_15_350 gfield_quantity gfield_quantity_15_350 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_427"><label class="gfield_label gform-field-label" for="input_15_427">Standard Wheelchair Qty<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_427" id="input_15_427" type="number" step="any" min="1" max="4" value="1" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_15_427">
<div class="gfield_description instruction " id="gfield_instruction_15_427">Please enter a number from <strong>1</strong> to <strong>4</strong>.</div>
</div>
</div>
<div id="field_15_349"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_349 gfield_product_15_349 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_349"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_349_1">Standard Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_349.1" value="Standard Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_349" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_349">$0.00</span>
</div>
<input type="hidden" name="input_349.2" id="ginput_base_price_15_349" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_349.3" value="1" class="ginput_quantity_15_349 gform_hidden">
</div>
</div>
<div id="field_15_351"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_351">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STANDARD-WC-TRANS-e1718162234823.png" alt=""></ul>
<p>4 Portable-Folds-300lbs capacity.</p>
</div>
<div id="field_15_352"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_352"><label class="gfield_label gform-field-label" for="input_15_352">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_352" id="input_15_352" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_352"></div>
<div class="gfield_description" id="gfield_description_15_352">**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_423" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_423">
<h3 class="gsection_title">Your Total Breakdown - Wheelchair Rental</h3>
<div class="gsection_description" id="gfield_description_15_423">*Select Quantity to Calculate your Total **Rental total include Taxes and Delivery/Pickup</div>
</div>
<div id="field_15_360"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_360 gfield_product_15_360 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_360"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_360_1"><span class="gfield_label_product gform-field-label">Standard Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_360.1" value="Standard Wheelchair" class="gform_hidden">
<div id="ginput_product_price_15_360" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_360">$0.00</span>
</div>
<input type="hidden" name="input_360.2" id="ginput_base_price_15_360" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_360.3" value="" id="input_15_360_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_360 gfield_description_15_360">
</div>
<div class="gfield_description" id="gfield_description_15_360">*Indicate Quantity</div>
</div>
<div id="field_15_361"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_361 gfield_product_15_361 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_361"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_361_1">Standard Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_361.1" value="Standard Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_361" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_361">$0.00</span>
</div>
<input type="hidden" name="input_361.2" id="ginput_base_price_15_361" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_361.3" value="1" class="ginput_quantity_15_361 gform_hidden">
</div>
</div>
<div id="field_15_362"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_362">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STANDARD-WC-TRANS-e1718162234823.png" alt=""></ul>
<p>4 Portable-Folds-300lbs capacity.</p>
</div>
<div id="field_15_363"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_363"><label class="gfield_label gform-field-label" for="input_15_363">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_363" id="input_15_363" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_363"></div>
<div class="gfield_description" id="gfield_description_15_363">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_353"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_353">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-300.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.</p>
</ul>
</div>
<div id="field_15_359" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_359">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">Transport WC</h3>
</div>
<div id="field_15_354"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_354 gfield_product_15_354 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_354"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_354_1"><span class="gfield_label_product gform-field-label">Transport Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_354.1" value="Transport Wheelchair" class="gform_hidden">
<div id="ginput_product_price_15_354" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_354">$0.00</span>
</div>
<input type="hidden" name="input_354.2" id="ginput_base_price_15_354" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_354.3" value="" id="input_15_354_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_354 gfield_description_15_354">
</div>
<div class="gfield_description" id="gfield_description_15_354">*Indicate Quantity</div>
</div>
<div id="field_15_355"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_355 gfield_product_15_355 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_355"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_355_1">Transport Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_355.1" value="Transport Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_355" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_355">$0.00</span>
</div>
<input type="hidden" name="input_355.2" id="ginput_base_price_15_355" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_355.3" value="1" class="ginput_quantity_15_355 gform_hidden">
</div>
</div>
<div id="field_15_356"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_356">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/imageedit_12_4649916590-e1718162519202.png" alt=""></ul>
<p>4 The smaller option, more portability than comfort-260 lbs weight capacity.</p>
</div>
<div id="field_15_357"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_357"><label class="gfield_label gform-field-label" for="input_15_357">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_357" id="input_15_357" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_357"></div>
<div class="gfield_description" id="gfield_description_15_357">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_358"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_358">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-260-e1717727666387.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE, CHOOSE EITHER A STANDARD OR HD WHEELCHAIR!!!!.</p>
</ul>
</div>
<div id="field_15_345" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_345">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">HD Wheelchair</h3>
</div>
<div id="field_15_364"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_364 gfield_product_15_364 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_364"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_364_1"><span class="gfield_label_product gform-field-label">Heavy Duty Wheelchair</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_364.1" value="Heavy Duty Wheelchair" class="gform_hidden">
<div id="ginput_product_price_15_364" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_364">$0.00</span>
</div>
<input type="hidden" name="input_364.2" id="ginput_base_price_15_364" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_364.3" value="" id="input_15_364_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_364 gfield_description_15_364">
</div>
<div class="gfield_description" id="gfield_description_15_364">*Indicate Quantity</div>
</div>
<div id="field_15_365"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_365 gfield_product_15_365 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_365"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_365_1">HD Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_365.1" value="HD Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_365" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_365">$0.00</span>
</div>
<input type="hidden" name="input_365.2" id="ginput_base_price_15_365" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_365.3" value="1" class="ginput_quantity_15_365 gform_hidden">
</div>
</div>
<div id="field_15_366"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_366">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/HD-WC-TRANS-e1718162738511.png" alt=""></ul>
<p>4 Resistant and comfortable-Up to 500 lbs capacity. Heavy but portable</p>
</div>
<div id="field_15_367"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_367"><label class="gfield_label gform-field-label" for="input_15_367">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_367" id="input_15_367" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_367"></div>
<div class="gfield_description" id="gfield_description_15_367">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_369" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_369">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">Electric Wheelchair</h3>
</div>
<div id="field_15_370"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_370 gfield_product_15_370 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_370"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_370_1"><span class="gfield_label_product gform-field-label">Electric Wheelchair (Travel Powerchair)</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_370.1" value="Electric Wheelchair (Travel Powerchair)" class="gform_hidden">
<div id="ginput_product_price_15_370" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_370">$0.00</span>
</div>
<input type="hidden" name="input_370.2" id="ginput_base_price_15_370" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_370.3" value="" id="input_15_370_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_370 gfield_description_15_370">
</div>
<div class="gfield_description" id="gfield_description_15_370">*Indicate Quantity</div>
</div>
<div id="field_15_371"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_371 gfield_product_15_371 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_371"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_371_1">Electric Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_371.1" value="Electric Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_371" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_371">$0.00</span>
</div>
<input type="hidden" name="input_371.2" id="ginput_base_price_15_371" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_371.3" value="1" class="ginput_quantity_15_371 gform_hidden">
</div>
</div>
<div id="field_15_372"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_372">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/ELECTRIC-TRANS-1-e1718162975911.png" alt=""></ul>
<p>4 Electric - Folds - Portable-Joystick operated-260 lbs capacity.</p>
</div>
<div id="field_15_373"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_373"><label class="gfield_label gform-field-label" for="input_15_373">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_373" id="input_15_373" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_373"></div>
<div class="gfield_description" id="gfield_description_15_373">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_374"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_374">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-260-e1717727666387.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.</p>
</ul>
</div>
<div id="field_15_393" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_393">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">Rollators</h3>
</div>
<fieldset id="field_15_402"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_402">
<legend class="gfield_label gform-field-label">Choose a Rollator/Walker Type<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_15_402">
<div class="gchoice gchoice_15_402_0">
<input class="gfield-choice-input" name="input_402" type="radio" value="Rollator Lite" id="choice_15_402_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_15_402">
<label for="choice_15_402_0" id="label_15_402_0" class="gform-field-label gform-field-label--type-inline">Rollator Lite</label>
</div>
<div class="gchoice gchoice_15_402_1">
<input class="gfield-choice-input" name="input_402" type="radio" value="Rollator Heavy Duty" id="choice_15_402_1" onchange="gformToggleRadioOther( this )">
<label for="choice_15_402_1" id="label_15_402_1" class="gform-field-label gform-field-label--type-inline">Rollator Heavy Duty</label>
</div>
<div class="gchoice gchoice_15_402_2">
<input class="gfield-choice-input" name="input_402" type="radio" value="Rollator-Wheelchair Combo" id="choice_15_402_2" onchange="gformToggleRadioOther( this )">
<label for="choice_15_402_2" id="label_15_402_2" class="gform-field-label gform-field-label--type-inline">Rollator-Wheelchair Combo</label>
</div>
</div>
</div>
<div class="gfield_description" id="gfield_description_15_402">*Rolllator lite 300lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity</div>
</fieldset>
<div id="field_15_403"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_403"><label class="gfield_label gform-field-label" for="input_15_403">Rollator User's Weight in Lbs<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_403" id="input_15_403" type="number" step="any" min="31" max="600" value="" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_15_403 gfield_description_15_403">
<div class="gfield_description instruction " id="gfield_instruction_15_403">Please enter a number from <strong>31</strong> to <strong>600</strong>.</div>
</div>
<div class="gfield_description" id="gfield_description_15_403">Check weight capacity limits. (KgsX2.2=Lbs)</div>
</div>
<div id="field_15_399"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_399">
<ul>
<li><img src="https://mexicomobility.mx/wp-content/uploads/2023/02/ROLLATOR-BANNER-2023-TRANS.png" alt=""></li>
</ul>
</div>
<div id="field_15_395"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_395 gfield_product_15_395 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_395"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_395_1">Rollator Lite<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_395.1" value="Rollator Lite" class="gform_hidden">
<div id="ginput_product_price_15_395" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_395">$0.00</span>
</div>
<input type="hidden" name="input_395.2" id="ginput_base_price_15_395" class="gform_hidden" value="$0.00">
</div>
<div class="gfield_description" id="gfield_description_15_395">*Price Per Day</div>
</div>
<div id="field_15_433"
class="gfield gfield--type-quantity gfield--input-type-number gfield--width-third gfield_price gfield_price_15_395 gfield_quantity gfield_quantity_15_395 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_433"><label class="gfield_label gform-field-label" for="input_15_433">Rollator Lite Qty<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_433" id="input_15_433" type="number" step="any" min="1" max="4" value="1" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_15_433">
<div class="gfield_description instruction " id="gfield_instruction_15_433">Please enter a number from <strong>1</strong> to <strong>4</strong>.</div>
</div>
</div>
<div id="field_15_404"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_404 gfield_product_15_404 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_404"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_404_1">Rollator Lite Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_404.1" value="Rollator Lite Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_404" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_404">$0.00</span>
</div>
<input type="hidden" name="input_404.2" id="ginput_base_price_15_404" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_404.3" value="1" class="ginput_quantity_15_404 gform_hidden">
</div>
</div>
<div id="field_15_396"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_396">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/LITE-TRANS-e1717820814525.png" alt=""></ul>
<p>4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and an under-seat storage pouch.</p>
</div>
<div id="field_15_397"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_397"><label class="gfield_label gform-field-label" for="input_15_397">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_397" id="input_15_397" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_397"></div>
<div class="gfield_description" id="gfield_description_15_397">**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_435" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_435">
<h3 class="gsection_title">Your Total Breakdown - Rollator Rental</h3>
<div class="gsection_description" id="gfield_description_15_435">*Select Quantity to Calculate your Total **Rental total include Taxes and Delivery/Pickup</div>
</div>
<div id="field_15_412"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_412 gfield_product_15_412 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_412"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_412_1"><span class="gfield_label_product gform-field-label">Rollator Lite</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_412.1" value="Rollator Lite" class="gform_hidden">
<div id="ginput_product_price_15_412" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_412">$0.00</span>
</div>
<input type="hidden" name="input_412.2" id="ginput_base_price_15_412" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_412.3" value="" id="input_15_412_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_412 gfield_description_15_412">
</div>
<div class="gfield_description" id="gfield_description_15_412">*Indicate Quantity</div>
</div>
<div id="field_15_413"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_413 gfield_product_15_413 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_413"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_413_1">Rollator Lite Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_413.1" value="Rollator Lite Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_413" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_413">$0.00</span>
</div>
<input type="hidden" name="input_413.2" id="ginput_base_price_15_413" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_413.3" value="1" class="ginput_quantity_15_413 gform_hidden">
</div>
</div>
<div id="field_15_414"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_414">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/LITE-TRANS-e1717820814525.png" alt=""></ul>
<p>4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and an under-seat storage pouch.</p>
</div>
<div id="field_15_415"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_415"><label class="gfield_label gform-field-label" for="input_15_415">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_415" id="input_15_415" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_415"></div>
<div class="gfield_description" id="gfield_description_15_415">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_405"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_405">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-260-e1717727666387.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE! SELECT A ROLLATOR HEAVY DUTY.</p>
</ul>
</div>
<div id="field_15_400"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_400 gfield_product_15_400 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_400"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_400_1"><span class="gfield_label_product gform-field-label">Rollator Heavy Duty</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_400.1" value="Rollator Heavy Duty" class="gform_hidden">
<div id="ginput_product_price_15_400" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_400">$0.00</span>
</div>
<input type="hidden" name="input_400.2" id="ginput_base_price_15_400" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_400.3" value="" id="input_15_400_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_400 gfield_description_15_400">
</div>
<div class="gfield_description" id="gfield_description_15_400">*Indicate Quantity</div>
</div>
<div id="field_15_401"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_401 gfield_product_15_401 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_401"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_401_1">Rollator HD Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_401.1" value="Rollator HD Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_401" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_401">$0.00</span>
</div>
<input type="hidden" name="input_401.2" id="ginput_base_price_15_401" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_401.3" value="1" class="ginput_quantity_15_401 gform_hidden">
</div>
</div>
<div id="field_15_408"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_408">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/HD-TRANS-e1717820828806.png" alt=""></ul>
<p>4 Rolling Walker with Seat: 500 lbs. Weigth Capacity. A comfortable seat, and an under-seat storage pouch.</p>
</div>
<div id="field_15_410"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_410"><label class="gfield_label gform-field-label" for="input_15_410">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_410" id="input_15_410" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_410"></div>
<div class="gfield_description" id="gfield_description_15_410">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_407"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_407 gfield_product_15_407 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_407"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_407_1"><span class="gfield_label_product gform-field-label">Rollator-Wheelchair Dual Unit</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_407.1" value="Rollator-Wheelchair Dual Unit" class="gform_hidden">
<div id="ginput_product_price_15_407" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_407">$0.00</span>
</div>
<input type="hidden" name="input_407.2" id="ginput_base_price_15_407" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_407.3" value="" id="input_15_407_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_407 gfield_description_15_407">
</div>
<div class="gfield_description" id="gfield_description_15_407">*Indicate Quantity</div>
</div>
<div id="field_15_406"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_406 gfield_product_15_406 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_406"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_406_1">Rollator-Wheelchair Dual Unit Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_406.1" value="Rollator-Wheelchair Dual Unit Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_406" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_406">$0.00</span>
</div>
<input type="hidden" name="input_406.2" id="ginput_base_price_15_406" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_406.3" value="1" class="ginput_quantity_15_406 gform_hidden">
</div>
</div>
<div id="field_15_409"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_409">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/ROLL-WC-TRANS-e1717820803784.png" alt=""></ul>
<p>4 Walker-Wheelchair dual unit: Stylish rolling walker with seat combines the features of a R Rollator and transport chair in one unit.</p>
</div>
<div id="field_15_411"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_411"><label class="gfield_label gform-field-label" for="input_15_411">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_411" id="input_15_411" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_411"></div>
<div class="gfield_description" id="gfield_description_15_411">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_375" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_375">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<h3 class="gsection_title">Oxygen Concentrators</h3>
</div>
<fieldset id="field_15_387"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_387">
<legend class="gfield_label gform-field-label">Select an Oxygen Device<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_15_387">
<div class="gchoice gchoice_15_387_0">
<input class="gfield-choice-input" name="input_387" type="radio" value="Stationary Oxygen Concentrator" id="choice_15_387_0" onchange="gformToggleRadioOther( this )">
<label for="choice_15_387_0" id="label_15_387_0" class="gform-field-label gform-field-label--type-inline">Stationary Oxygen Concentrator</label>
</div>
<div class="gchoice gchoice_15_387_1">
<input class="gfield-choice-input" name="input_387" type="radio" value="Portable Oxygen Concentrator" id="choice_15_387_1" onchange="gformToggleRadioOther( this )">
<label for="choice_15_387_1" id="label_15_387_1" class="gform-field-label gform-field-label--type-inline">Portable Oxygen Concentrator</label>
</div>
<div class="gchoice gchoice_15_387_2">
<input class="gfield-choice-input" name="input_387" type="radio" value="CPAP Machine" id="choice_15_387_2" onchange="gformToggleRadioOther( this )">
<label for="choice_15_387_2" id="label_15_387_2" class="gform-field-label gform-field-label--type-inline">CPAP Machine</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_388"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_388">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/OXYGEN-TYPES-TRANS-e1717879224219.png" alt=""></ul>
</div>
<div id="field_15_416"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_416 gfield_product_15_416 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_416"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_416_1">Stationary Oxygen Concentrator<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_416.1" value="Stationary Oxygen Concentrator" class="gform_hidden">
<div id="ginput_product_price_15_416" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_416">$0.00</span>
</div>
<input type="hidden" name="input_416.2" id="ginput_base_price_15_416" class="gform_hidden" value="$0.00">
</div>
<div class="gfield_description" id="gfield_description_15_416">*Indicate Quantity</div>
</div>
<div id="field_15_434"
class="gfield gfield--type-quantity gfield--input-type-number gfield--width-third gfield_price gfield_price_15_416 gfield_quantity gfield_quantity_15_416 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_434"><label class="gfield_label gform-field-label" for="input_15_434">Stationary Oxygen Concentrator Qty<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_434" id="input_15_434" type="number" step="any" min="1" max="4" value="1" class="small" aria-required="true" aria-invalid="false"
aria-describedby="gfield_instruction_15_434">
<div class="gfield_description instruction " id="gfield_instruction_15_434">Please enter a number from <strong>1</strong> to <strong>4</strong>.</div>
</div>
</div>
<div id="field_15_417"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-third gfield_price gfield_price_15_417 gfield_product_15_417 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_417"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_417_1">Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_417.1" value="Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_417" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_417">$0.00</span>
</div>
<input type="hidden" name="input_417.2" id="ginput_base_price_15_417" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_417.3" value="1" class="ginput_quantity_15_417 gform_hidden">
</div>
</div>
<div id="field_15_419"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_419">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STATIONARY-TRANS-e1717879738455.png" alt=""></ul>
<ul>
</ul>
</div>
<div id="field_15_420"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_420"><label class="gfield_label gform-field-label" for="input_15_420">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_420" id="input_15_420" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_420"></div>
<div class="gfield_description" id="gfield_description_15_420">**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_377"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_377 gfield_product_15_377 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_377"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_377_1"><span class="gfield_label_product gform-field-label">Stationary Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_377.1" value="Stationary Oxygen Concentrator" class="gform_hidden">
<div id="ginput_product_price_15_377" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_377">$0.00</span>
</div>
<input type="hidden" name="input_377.2" id="ginput_base_price_15_377" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_377.3" value="" id="input_15_377_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_377 gfield_description_15_377">
</div>
<div class="gfield_description" id="gfield_description_15_377">*Indicate Quantity</div>
</div>
<div id="field_15_376"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_376 gfield_product_15_376 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_376"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_376_1">Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_376.1" value="Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_376" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_376">$0.00</span>
</div>
<input type="hidden" name="input_376.2" id="ginput_base_price_15_376" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_376.3" value="1" class="ginput_quantity_15_376 gform_hidden">
</div>
</div>
<div id="field_15_378"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_378">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STATIONARY-TRANS-e1717879738455.png" alt=""></ul>
<ul>
</ul>
</div>
<div id="field_15_384"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_384"><label class="gfield_label gform-field-label" for="input_15_384">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_384" id="input_15_384" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_384"></div>
<div class="gfield_description" id="gfield_description_15_384">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_389"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_389 gfield_product_15_389 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_389"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_389_1"><span class="gfield_label_product gform-field-label">Portable Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_389.1" value="Portable Oxygen Concentrator" class="gform_hidden">
<div id="ginput_product_price_15_389" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_389">$0.00</span>
</div>
<input type="hidden" name="input_389.2" id="ginput_base_price_15_389" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_389.3" value="" id="input_15_389_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_389 gfield_description_15_389">
</div>
<div class="gfield_description" id="gfield_description_15_389">*Indicate Quantity</div>
</div>
<div id="field_15_390"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_390 gfield_product_15_390 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_390"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_390_1">Portable Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_390.1" value="Portable Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_390" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_390">$0.00</span>
</div>
<input type="hidden" name="input_390.2" id="ginput_base_price_15_390" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_390.3" value="1" class="ginput_quantity_15_390 gform_hidden">
</div>
</div>
<div id="field_15_391"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_391">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/PORTABLE-TRANS-e1717880044368.png" alt=""></ul>
<ul>
</ul>
</div>
<div id="field_15_392"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_392"><label class="gfield_label gform-field-label" for="input_15_392">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_392" id="input_15_392" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_392"></div>
<div class="gfield_description" id="gfield_description_15_392">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_381"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_381 gfield_product_15_381 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_381"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_381_1"><span class="gfield_label_product gform-field-label">CPAP Machine</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_381.1" value="CPAP Machine" class="gform_hidden">
<div id="ginput_product_price_15_381" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_381">$0.00</span>
</div>
<input type="hidden" name="input_381.2" id="ginput_base_price_15_381" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_381.3" value="" id="input_15_381_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_381 gfield_description_15_381">
</div>
<div class="gfield_description" id="gfield_description_15_381">**Indicate Quantity</div>
</div>
<div id="field_15_382"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_382 gfield_product_15_382 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_382"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_382_1">CPAP Machine Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_382.1" value="CPAP Machine Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_382" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_382">$0.00</span>
</div>
<input type="hidden" name="input_382.2" id="ginput_base_price_15_382" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_382.3" value="1" class="ginput_quantity_15_382 gform_hidden">
</div>
</div>
<div id="field_15_383"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_383">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/CPAP-TRANS-e1717880034102.png" alt=""></ul>
<ul></ul>
</div>
<div id="field_15_379"
class="gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_379"><label class="gfield_label gform-field-label" for="input_15_379">Rental Total<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_379" id="input_15_379" type="text" step="any" value="" class="small" readonly="readonly" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_379"></div>
<div class="gfield_description" id="gfield_description_15_379">*Taxes & Delivery/Pick up Incl.</div>
</div>
<div id="field_15_426" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_426">
<h3 class="gsection_title"></h3>
<div class="gsection_description" id="gfield_description_15_426">Next Button Enables Once a 3 day length or Longer Rental Period is Chosen.</div>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2024/09/2593265_arrow_fast-forward_next-button_pointer_icon-5.png" id="gform_next_button_15_277" class="gform_next_button gform-theme-button button gform_image_button"
alt="Next Page" onclick="jQuery("#gform_target_page_number_15").val("2"); jQuery("#gform_15").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_15").val("2"); jQuery("#gform_15").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_15_2" class="gform_page" data-js="page-field-id-277" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_15_2" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_15_55"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_55"><label class="gfield_label gform-field-label" for="input_15_55">City of Service<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_55" id="input_15_55" class="medium gfield_select" aria-describedby="gfield_description_15_55" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select City</option>
<option value="Los Cabos, Mexico">Los Cabos, Mexico</option>
<option value="Cancun, Mexico">Cancun, Mexico</option>
<option value="Cozumel, Mexico">Cozumel, Mexico</option>
<option value="Puerto Vallarta, Mexico">Puerto Vallarta, Mexico</option>
<option value="La Paz, Mexico">La Paz, Mexico</option>
<option value="Loreto, Mexico">Loreto, Mexico</option>
<option value="Mazatlan, Mexico">Mazatlan, Mexico</option>
<option value="Merida, Mexico">Merida, Mexico</option>
<option value="Playa Del Carmen, Mexico">Playa Del Carmen, Mexico</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_55">Choose your rental destination. If not listed, then we cannot provide your rental.</div>
</div>
<div id="field_15_8"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_8"><label class="gfield_label gform-field-label" for="input_15_8">Describe Your Mobility Disability<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_8" id="input_15_8" class="medium gfield_select" aria-describedby="gfield_description_15_8" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Limited Walking Capacity">Limited Walking Capacity</option>
<option value="Elderly">Elderly</option>
<option value="Absent limb/reduced limb function">Absent limb/reduced limb function</option>
<option value="Paraplegia">Paraplegia</option>
<option value="Quadriplegia">Quadriplegia</option>
<option value="Hemiplegia">Hemiplegia</option>
<option value="Dystrophy">Dystrophy</option>
<option value="Other">Other</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_8">This information Help us to assign the best equipment to fullfil your needs</div>
</div>
<div id="field_15_42"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_42"><label class="gfield_label gform-field-label" for="input_15_42">Have you used a Scooter/Powerchair before?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_42" id="input_15_42" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
</div>
<div id="field_15_66"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_66"><label class="gfield_label gform-field-label" for="input_15_66">Add an Oxygen Device?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_66" id="input_15_66" class="small gfield_select" aria-describedby="gfield_description_15_66" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_66">If yes, you will be ask for more details later in the form.</div>
</div>
<fieldset id="field_15_315"
class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_315">
<legend class="gfield_label gform-field-label">Select an Oxygen Device<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_15_315">
<div class="gchoice gchoice_15_315_0">
<input class="gfield-choice-input" name="input_315" type="radio" value="Stationary Oxygen Concentrator" id="choice_15_315_0" onchange="gformToggleRadioOther( this )">
<label for="choice_15_315_0" id="label_15_315_0" class="gform-field-label gform-field-label--type-inline">Stationary Oxygen Concentrator</label>
</div>
<div class="gchoice gchoice_15_315_1">
<input class="gfield-choice-input" name="input_315" type="radio" value="Portable Oxygen Concentrator" id="choice_15_315_1" onchange="gformToggleRadioOther( this )">
<label for="choice_15_315_1" id="label_15_315_1" class="gform-field-label gform-field-label--type-inline">Portable Oxygen Concentrator</label>
</div>
<div class="gchoice gchoice_15_315_2">
<input class="gfield-choice-input" name="input_315" type="radio" value="CPAP Machine" id="choice_15_315_2" onchange="gformToggleRadioOther( this )">
<label for="choice_15_315_2" id="label_15_315_2" class="gform-field-label gform-field-label--type-inline">CPAP Machine</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_316"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_316">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/OXYGEN-TYPES-TRANS-e1717879224219.png" alt=""></ul>
</div>
<div id="field_15_317"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_left_half gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_317">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/STATIONARY-TRANS-e1717879738455.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_318"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gf_right_half gfield--width-half gfield_price gfield_price_15_318 gfield_product_15_318 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_318"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_318_1"><span class="gfield_label_product gform-field-label">Stationary Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_318.1" value="Stationary Oxygen Concentrator" class="gform_hidden">
<div id="ginput_product_price_15_318" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_318">$0.00</span>
</div>
<input type="hidden" name="input_318.2" id="ginput_base_price_15_318" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_318.3" value="" id="input_15_318_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_318 gfield_description_15_318">
</div>
<div class="gfield_description" id="gfield_description_15_318">**Indicate Quantity</div>
</div>
<div id="field_15_319"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_left_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_319">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/PORTABLE-TRANS-e1717880044368.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_320"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gf_right_half gfield--width-half gfield_price gfield_price_15_320 gfield_product_15_320 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_320"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_320_1"><span class="gfield_label_product gform-field-label">Portable Oxygen Concentrator</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_320.1" value="Portable Oxygen Concentrator" class="gform_hidden">
<div id="ginput_product_price_15_320" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_320">$0.00</span>
</div>
<input type="hidden" name="input_320.2" id="ginput_base_price_15_320" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_320.3" value="" id="input_15_320_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_320 gfield_description_15_320">
</div>
<div class="gfield_description" id="gfield_description_15_320">**Indicate Quantity</div>
</div>
<div id="field_15_321"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_left_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_321">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/CPAP-TRANS-e1717880034102.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_322"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gf_right_half gfield--width-half gfield_price gfield_price_15_322 gfield_product_15_322 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_322"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_322_1"><span class="gfield_label_product gform-field-label">CPAP Machine</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_322.1" value="CPAP Machine" class="gform_hidden">
<div id="ginput_product_price_15_322" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_322">$0.00</span>
</div>
<input type="hidden" name="input_322.2" id="ginput_base_price_15_322" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_322.3" value="" id="input_15_322_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_322 gfield_description_15_322">
</div>
<div class="gfield_description" id="gfield_description_15_322">**Indicate Quantity</div>
</div>
<div id="field_15_329"
class="gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_329"><label class="gfield_label gform-field-label" for="input_15_329">Add a CPAP Nasal Mask?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_329" id="input_15_329" class="small gfield_select" aria-describedby="gfield_description_15_329" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_329">AVAILABLE NASAL MASKS ONLY</div>
</div>
<div id="field_15_324"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gf_right_half gfield--width-half gfield_price gfield_price_15_324 gfield_product_15_324 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_324"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_324_1"><span class="gfield_label_product gform-field-label">CPAP Nasal Mask with Headgear</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_324.1" value="CPAP Nasal Mask with Headgear" class="gform_hidden">
<div id="ginput_product_price_15_324" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_324">$0.00</span>
</div>
<input type="hidden" name="input_324.2" id="ginput_base_price_15_324" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_324.3" value="" id="input_15_324_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_324 gfield_description_15_324">
</div>
<div class="gfield_description" id="gfield_description_15_324">**Indicate Quantity</div>
</div>
<div id="field_15_330"
class="gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_330"><label class="gfield_label gform-field-label" for="input_15_330">Add a CPAP Tubing?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_330" id="input_15_330" class="small gfield_select" aria-describedby="gfield_description_15_330" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_330">***If your tube has a heating device, you ll need a standard tubing****</div>
</div>
<div id="field_15_328"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_left_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_328">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/CPAP-TUBING-e1717882617321.png" alt=""></ul>
<ul>
<p>4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.</p>
</ul>
</div>
<div id="field_15_326"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gf_right_half gfield--width-half gfield_price gfield_price_15_326 gfield_product_15_326 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_326"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_326_1"><span class="gfield_label_product gform-field-label">CPAP Tubing</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_326.1" value="CPAP Tubing" class="gform_hidden">
<div id="ginput_product_price_15_326" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_326">$0.00</span>
</div>
<input type="hidden" name="input_326.2" id="ginput_base_price_15_326" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_326.3" value="" id="input_15_326_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_326 gfield_description_15_326">
</div>
<div class="gfield_description" id="gfield_description_15_326">**Indicate Quantity</div>
</div>
<fieldset id="field_15_189"
class="gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full standard-wrap gfield_price gfield_price_15_189 gfield_product_15_189 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_189">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div>
<legend class="gfield_label gform-field-label">STAND-N-RIDE SCOOTER<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_15_189">
<div class="gchoice gchoice_15_189_0">
<input class="gfield-choice-input" name="input_189" type="radio" value="STAND-N-RIDE SCOOTER|0" id="choice_15_189_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_15_189">
<label for="choice_15_189_0" id="label_15_189_0" class="gform-field-label gform-field-label--type-inline">STAND-N-RIDE SCOOTER</label>
</div>
</div>
</div>
<div class="gfield_description" id="gfield_description_15_189">Personal Transporter for NON-DISABLED ADULT USERS ONLY!</div>
</fieldset>
<div id="field_15_239"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden"
data-js-reload="field_15_239">
<ul>
<li><img src="https://mexicomobility.mx/wp-content/uploads/2022/11/STAND-N-RIDE-SCOOTER-TRANS-SMALL-COMBO.png
" alt=""></li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>For user's weighting 260 lbs or less ONLY. Smooth, Quiet, Non-Intrusive. 15 MPH Top Speed. 20 miles battery range. Removable Seat for Free Standing operation.</p>
</li>
</ul>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2024/09/2593267_arrow_back-button_pointer_preview_icon-6.png" id="gform_previous_button_15_10"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="jQuery("#gform_target_page_number_15").val("1"); jQuery("#gform_15").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_15").val("1"); jQuery("#gform_15").trigger("submit",[true]); } "> <input type="image"
src="https://mexicomobility.com/wp-content/uploads/2024/09/2593265_arrow_fast-forward_next-button_pointer_icon-5.png" id="gform_next_button_15_10" class="gform_next_button gform-theme-button button gform_image_button" alt="Next Page"
onclick="jQuery("#gform_target_page_number_15").val("3"); jQuery("#gform_15").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_15").val("3"); jQuery("#gform_15").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_15_3" class="gform_page" data-js="page-field-id-10" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_15_3" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_15_309"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_309"><label class="gfield_label gform-field-label" for="input_15_309">Deliver to<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_309" id="input_15_309" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select Place</option>
<option value="Hotel">Hotel</option>
<option value="Home">Home</option>
</select></div>
</div>
<div id="field_15_41"
class="gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_41"><label class="gfield_label gform-field-label" for="input_15_41">Hotel name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_41" id="input_15_41" type="text" value="" class="medium" placeholder="Hilton" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_95"
class="gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_95">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Address to Deliver<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_street ginput_container_address gform-grid-row" id="input_15_95">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_15_95_1_container">
<input type="text" name="input_95.1" id="input_15_95_1" value="" placeholder="Be Accurate" aria-required="true">
<label for="input_15_95_1" id="input_15_95_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><input type="hidden" class="gform_hidden" name="input_95.4" id="input_15_95_4" value=""><input type="hidden" class="gform_hidden" name="input_95.6" id="input_15_95_6" value="">
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_15_23"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_23"><label class="gfield_label gform-field-label" for="input_15_23">How did you find us?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_23" id="input_15_23" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select an option</option>
<option value="Trip advisor">Trip advisor</option>
<option value="Facebook Ad">Facebook Ad</option>
<option value="Google Ad">Google Ad</option>
<option value="Our Facebook Site">Our Facebook Site</option>
<option value="Web Search (Random)">Web Search (Random)</option>
<option value="Returning costumer">Returning costumer</option>
<option value="Concierge or Bell Boy Referral">Concierge or Bell Boy Referral</option>
<option value="Other costumer recommended">Other costumer recommended</option>
</select></div>
</div>
<div id="field_15_137"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_137"><label class="gfield_label gform-field-label" for="input_15_137">Any special Need?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_137" id="input_15_137" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
</div>
<div id="field_15_22"
class="gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_22"><label class="gfield_label gform-field-label" for="input_15_22">Indicate any special need or concern.<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_22" id="input_15_22" class="textarea small" maxlength="300" placeholder="Tell us" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea>
</div>
</div>
<div id="field_15_253"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_253"><label class="gfield_label gform-field-label" for="input_15_253">Add a Rollator/Walker?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_253" id="input_15_253" class="medium gfield_select" aria-describedby="gfield_description_15_253" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Indicate</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_253">*Rollator rental rates as an ADDON item are reduced compared with as a primary rental item.</div>
</div>
<div id="field_15_149"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_149"><label class="gfield_label gform-field-label" for="input_15_149">Pay With:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_149" id="input_15_149" class="medium gfield_select" aria-describedby="gfield_description_15_149" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="Credit / Debit Card">Credit / Debit Card</option>
<option value="Pay Pal">Pay Pal</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_149">Choose Payment Method</div>
</div>
<div id="field_15_254"
class="gfield gfield--type-product gfield--input-type-select gfield--width-full gfield_price gfield_price_15_254 gfield_product_15_254 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_254"><label class="gfield_label gform-field-label" for="input_15_254">Choose a Rollator/Walker Type<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_254" id="input_15_254" class="small gfield_select" aria-describedby="gfield_description_15_254" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Choose</option>
<option value="Rollator Lite|0">Rollator Lite</option>
<option value="Rollator Heavy Duty|0">Rollator Heavy Duty</option>
<option value="Rollator-Wheelchair Combo|0">Rollator-Wheelchair Combo</option>
</select></div>
<div class="gfield_description" id="gfield_description_15_254">*Rolllator lite 300lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity</div>
</div>
<div id="field_15_255"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_255">
<ul>
<li><img src="https://mexicomobility.mx/wp-content/uploads/2023/02/ROLLATOR-BANNER-2023-TRANS.png" alt=""></li>
</ul>
</div>
<div id="field_15_300"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_300">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/LITE-TRANS-e1717820814525.png" alt=""></ul>
<p>4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and an under-seat storage pouch.</p>
</div>
<div id="field_15_297"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_297 gfield_product_15_297 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_297"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_297_1"><span class="gfield_label_product gform-field-label">Rollator Lite</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_297.1" value="Rollator Lite" class="gform_hidden">
<div id="ginput_product_price_15_297" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_297">$0.00</span>
</div>
<input type="hidden" name="input_297.2" id="ginput_base_price_15_297" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_297.3" value="" id="input_15_297_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_297 gfield_description_15_297">
</div>
<div class="gfield_description" id="gfield_description_15_297">**Indicate Quantity</div>
</div>
<div id="field_15_305"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_305">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-260-e1717727666387.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE, CHOOSE A ROLLATOR HD!!!!.</p>
</ul>
</div>
<div id="field_15_301"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_301">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/HD-TRANS-e1717820828806.png" alt=""></ul>
<p>4 Rolling Walker with Seat: 500 lbs. Weigth Capacity. A comfortable seat, and an under-seat storage pouch.</p>
</div>
<div id="field_15_298"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_298 gfield_product_15_298 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_298"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_298_1"><span class="gfield_label_product gform-field-label">Rollator Heavy Duty</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_298.1" value="Rollator Heavy Duty" class="gform_hidden">
<div id="ginput_product_price_15_298" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_298">$0.00</span>
</div>
<input type="hidden" name="input_298.2" id="ginput_base_price_15_298" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_298.3" value="" id="input_15_298_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_298 gfield_description_15_298">
</div>
<div class="gfield_description" id="gfield_description_15_298">**Indicate Quantity</div>
</div>
<div id="field_15_302"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_302">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/ROLL-WC-TRANS-e1717820803784.png" alt=""></ul>
<p>4 Walker-Wheelchair dual unit: Stylish rolling walker with seat combines the features of a R Rollator and transport chair in one unit.</p>
</div>
<div id="field_15_299"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-half gfield_price gfield_price_15_299 gfield_product_15_299 gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_299"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_299_1"><span class="gfield_label_product gform-field-label">Rollator-Wheelchair Dual Unit</span> <span
class="screen-reader-text">Quantity</span><span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_299.1" value="Rollator-Wheelchair Dual Unit" class="gform_hidden">
<div id="ginput_product_price_15_299" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_299">$0.00</span>
</div>
<input type="hidden" name="input_299.2" id="ginput_base_price_15_299" class="gform_hidden" value="$0.00">
<span class="ginput_quantity_label gform-field-label" aria-hidden="true">Quantity</span> <input type="number" name="input_299.3" value="" id="input_15_299_1" class="ginput_quantity" size="10" min="0"
aria-describedby="ginput_product_price_15_299 gfield_description_15_299">
</div>
<div class="gfield_description" id="gfield_description_15_299">**Indicate Quantity</div>
</div>
<div id="field_15_306"
class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_right_half gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_306">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/Warning-300.png" alt=""></ul>
<ul>
<p> !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.</p>
</ul>
</div>
</div>
</div>
<div class="gform_page_footer top_label">
<input type="image" src="https://mexicomobility.com/wp-content/uploads/2024/09/2593267_arrow_back-button_pointer_preview_icon-6.png" id="gform_previous_button_15_24"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="jQuery("#gform_target_page_number_15").val("2"); jQuery("#gform_15").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_15").val("2"); jQuery("#gform_15").trigger("submit",[true]); } "> <input type="image"
src="https://mexicomobility.com/wp-content/uploads/2024/09/2593265_arrow_fast-forward_next-button_pointer_icon-5.png" id="gform_next_button_15_24" class="gform_next_button gform-theme-button button gform_image_button" alt="Next Page"
onclick="jQuery("#gform_target_page_number_15").val("4"); jQuery("#gform_15").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_15").val("4"); jQuery("#gform_15").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_15_4" class="gform_page" data-js="page-field-id-24" style="display:none;">
<div class="gform_page_fields">
<div id="gform_fields_15_4" class="gform_fields top_label form_sublabel_below description_below validation_below">
<fieldset id="field_15_178"
class="gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_178">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Renter Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_15_178">
<span id="input_15_178_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_178.3" id="input_15_178_3" value="" aria-required="true" placeholder="John">
<label for="input_15_178_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_15_178_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_178.6" id="input_15_178_6" value="" aria-required="true" placeholder="Smith">
<label for="input_15_178_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</fieldset>
<div id="field_15_64"
class="gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_64"><label class="gfield_label gform-field-label" for="input_15_64">Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_64" id="input_15_64" type="tel" value="" class="medium" placeholder="Mobile Number" aria-required="true" aria-invalid="false"
aria-describedby="gfield_description_15_64"></div>
<div class="gfield_description" id="gfield_description_15_64">(Country code + Phone number)</div>
</div>
<fieldset id="field_15_38"
class="gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_38">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container_email gform-grid-row" id="input_15_38_container">
<span id="input_15_38_1_container" class="ginput_left gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_38" id="input_15_38" value="" aria-required="true" aria-invalid="false">
<label for="input_15_38" class="gform-field-label gform-field-label--type-sub ">Enter Email</label>
</span>
<span id="input_15_38_2_container" class="ginput_right gform-grid-col gform-grid-col--size-auto">
<input class="" type="email" name="input_38_2" id="input_15_38_2" value="" aria-required="true" aria-invalid="false">
<label for="input_15_38_2" class="gform-field-label gform-field-label--type-sub ">Confirm Email</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_15_54"
class="gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_54"><label class="gfield_label gform-field-label" for="input_15_54">Country<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_54" id="input_15_54" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Congo, Republic of the">Congo, Republic of the</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Norway">Norway</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia and Montenegro">Serbia and Montenegro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Sudan, South">Sudan, South</option>
<option value="Suriname">Suriname</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States" selected="selected">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select></div>
</div>
<div id="field_15_436" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_436">
<h3 class="gsection_title"></h3>
</div>
<div id="field_15_313"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_313 gfield_product_15_313 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_313"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_313_1">Rollator Lite Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_313.1" value="Rollator Lite Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_313" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_313">$0.00</span>
</div>
<input type="hidden" name="input_313.2" id="ginput_base_price_15_313" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_313.3" value="1" class="ginput_quantity_15_313 gform_hidden">
</div>
</div>
<div id="field_15_335"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_335 gfield_product_15_335 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_335"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_335_1">Rollator HD Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_335.1" value="Rollator HD Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_335" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_335">$0.00</span>
</div>
<input type="hidden" name="input_335.2" id="ginput_base_price_15_335" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_335.3" value="1" class="ginput_quantity_15_335 gform_hidden">
</div>
</div>
<div id="field_15_336"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_336 gfield_product_15_336 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_336"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_336_1">Rollator-Wheelchair Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_336.1" value="Rollator-Wheelchair Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_336" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_336">$0.00</span>
</div>
<input type="hidden" name="input_336.2" id="ginput_base_price_15_336" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_336.3" value="1" class="ginput_quantity_15_336 gform_hidden">
</div>
</div>
<div id="field_15_314"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_314 gfield_product_15_314 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_314"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_314_1">Portable Oxygen Concentrator Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_314.1" value="Portable Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_314" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_314">$0.00</span>
</div>
<input type="hidden" name="input_314.2" id="ginput_base_price_15_314" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_314.3" value="1" class="ginput_quantity_15_314 gform_hidden">
</div>
</div>
<div id="field_15_337"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_337 gfield_product_15_337 gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_337"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_337_1">Oxygen Concentrator Delivery & Pick up fee</label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_337.1" value="Oxygen Concentrator Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_337" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_337">$0.00</span>
</div>
<input type="hidden" name="input_337.2" id="ginput_base_price_15_337" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_337.3" value="1" class="ginput_quantity_15_337 gform_hidden">
</div>
</div>
<div id="field_15_338"
class="gfield gfield--type-product gfield--input-type-calculation gfield--width-full gfield_price gfield_price_15_338 gfield_product_15_338 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_338"><label class="gfield_label gform-field-label gfield_label_before_complex" for="input_15_338_1">CPAP Delivery & Pick up fee<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_product_calculation">
<input type="hidden" name="input_338.1" value="CPAP Delivery & Pick up fee" class="gform_hidden">
<div id="ginput_product_price_15_338" class="ginput_product_price_wrapper">
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price_label">Price:</span>
<span class="gform-field-label gform-field-label--type-sub-large ginput_product_price" id="input_15_338">$0.00</span>
</div>
<input type="hidden" name="input_338.2" id="ginput_base_price_15_338" class="gform_hidden" value="$0.00">
<input type="hidden" name="input_338.3" value="1" class="ginput_quantity_15_338 gform_hidden">
</div>
</div>
<div id="field_15_217"
class="gfield gfield--type-total gfield--input-type-total gfield--width-half gfield_price gfield_price_15_ gfield_total gfield_total_15_ field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
aria-atomic="true" aria-live="polite" data-js-reload="field_15_217"><label class="gfield_label gform-field-label" for="input_15_217">Rental Total</label>
<div class="ginput_container ginput_container_total">
<input type="text" readonly="" name="input_217" id="input_15_217" value="$0.00" class="gform-text-input-reset ginput_total ginput_total_15">
</div>
<div class="gfield_description" id="gfield_description_15_217">Total in USD, Taxes, Delivery & Pick up incl.</div>
</div>
<div id="field_15_216"
class="gfield gfield--type-stripe_creditcard gfield--input-type-stripe_creditcard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-payment-element"
data-js-reload="field_15_216"><label class="gfield_label gfield_label_before_complex gform-field-label" for="input_15_216_1">Credit / Debit Card<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row" id="input_15_216">
<div class="ginput_full gform-grid-col" id="input_15_216_1_container" data-payment-element="true">
<div id="input_15_216_1" class="StripeElement--payment-element"></div>
</div><!-- .ginput_full -->
</div><!-- .ginput_container -->
<style type="text/css">
:root {
--link-login-string: "Link login"
}
</style>
</div>
<fieldset id="field_15_37"
class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_37">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Read Terms & Conditions Before Completing Reservation!<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span>
</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_37">
<div class="gchoice gchoice_15_37_1">
<input class="gfield-choice-input" name="input_37.1" type="checkbox" value="I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy" id="choice_15_37_1"
aria-describedby="gfield_description_15_37">
<label for="choice_15_37_1" id="label_15_37_1" class="gform-field-label gform-field-label--type-inline">I agree to the <div class="form-terms">Terms and Conditions</div> | Privacy Policy</label>
</div>
</div>
</div>
<div class="gfield_description" id="gfield_description_15_37">READ Cancellation Policy!</div>
</fieldset>
<div id="field_15_331"
class="gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_331">
<ul><img src="https://mexicomobility.mx/wp-content/uploads/2024/06/CANCELLATION-POLICY-COVID-2020-21-e1717959365487.png" alt=""></ul>
</div>
</div>
</div>
<div class="gform_page_footer top_label"><input type="image" src="https://mexicomobility.com/wp-content/uploads/2024/09/2593267_arrow_back-button_pointer_preview_icon-6.png" id="gform_previous_button_15"
class="gform_previous_button gform-theme-button gform-theme-button--secondary button gform_image_button" alt="Previous Page"
onclick="if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} jQuery("#gform_15").trigger("submit",[true]); }">
<input type="submit" id="gform_submit_button_15" class="gform_button button" value="Book Rental"
onclick="if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} jQuery("#gform_15").trigger("submit",[true]); }">
<input type="hidden" name="gform_ajax" value="form_id=15&title=1&description=1&tabindex=0&theme=gravity-theme">
<input type="hidden" class="gform_hidden" name="is_submit_15" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="15">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
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data-js-reload="field_11_41">
<legend class="gfield_label gform-field-label">Select User's Weight<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
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<div class="gfield_radio" id="input_11_41">
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<input class="gfield-choice-input" name="input_41" type="radio" value="<260 lbs (<120 kgs)" id="choice_11_41_0" onchange="gformToggleRadioOther( this )" aria-describedby="gfield_description_11_41">
<label for="choice_11_41_0" id="label_11_41_0" class="gform-field-label gform-field-label--type-inline"><260 lbs (<120 kgs)</label>
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<label for="choice_11_41_1" id="label_11_41_1" class="gform-field-label gform-field-label--type-inline">261-340 lbs (120 - 160 kgs)</label>
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<div class="gfield_description" id="gfield_description_11_41">Some ITEMS are shown or hidden based on Equipment Weight Capacity for best performance.</div>
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<option value="Travel Scooter">Travel Scooter</option>
<option value="Standard Scooter">Standard Scooter</option>
<option value="HD (Medium) Scooter">HD (Medium) Scooter</option>
<option value="HD (Full size) Scooter">HD (Full size) Scooter</option>
<option value="Standard Wheelchair">Standard Wheelchair</option>
<option value="Heavy Duty Wheelchair">Heavy Duty Wheelchair</option>
<option value="Powerchair">Powerchair</option>
<option value="Stand N Ride (Non disabled ONLY)">Stand N Ride (Non disabled ONLY)</option>
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<div class="gfield_description" id="gfield_description_11_44">Important: Check Unit Weight Capacity to choose the right one for you and have its best performance.</div>
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<option value="Yes">Yes</option>
<option value="No">No</option>
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<div class="gfield_description" id="gfield_description_11_38">The Stand N Ride scooter is FOR NON DISABLED NON ELEDERLY USERS ONLY. Otherwise the risk of falling is very high.</div>
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<div id="field_11_5" class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_5">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/TRAVEL-SCOOTER-GOGO-CHECKFRONT.png" alt="">
<img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-260.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>4 Wheels Design Allows for a Highly Maneuverable 34nch Turning Radius</p>
</li>
<li><i class="fa fa-check"></i>
<p>Top Speed of 4.5 MPH / Range of 12 Miles</p>
</li>
<li><i class="fa fa-check"></i>
<p> Fully Disassemble to 4 Pieces.</p>
</li>
<li><i class="fa fa-check"></i>
<p> TOP WEIGHT CAPACITY 260 lbs.</p>
</li>
</ul>
</div>
<div id="field_11_6"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_6">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/STANDARD-REVO-CHECKFRONT.png" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-325.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Transportable 4 Wheel Scooter</p>
</li>
<li><i class="fa fa-check"></i>
<p>4 Wheel Design Allows for Maximum Stability, 40 Inch Turning Radius.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Top Speed of 4.5 MPH and a Cruising range of 12 Miles.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Fully Disassemble to 4 Pieces in Matter of Seconds, and Can Easily Fit into the Trunk of an Car.</p>
</li>
<li><i class="fa fa-check"></i>
<p>TOP WEIGHT CAPACITY 325 lbs.</p>
</li>
</ul>
</div>
<div id="field_11_7"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_7">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/MAXIMA-SMALL-1.png" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-500.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>The Stylish , high-performing scooter</p>
</li>
<li><i class="fa fa-check"></i>
<p>TOP Weight Capacity: 500 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p>Batter Range: 11 Miles.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Scooter / Batter Weight: 150 / 65 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p>FITS ELEVATORS AND ROOM DOORS.</p>
</li>
<li><i class="fa fa-check"></i>
<p>FITS MEDIUM SIZE VANS.</p>
</li>
</ul>
</div>
<div id="field_11_10"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_10">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/HD-SCOOTER-MAXIMA-CHECKFRONT.png" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-500-Do-not-fit.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>The Stylish , high-performing scooter</p>
</li>
<li><i class="fa fa-check"></i>
<p>Weight Capacity: 500 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p>Batter Range: 11 Miles.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Scooter / Batter Weight: 150 / 65 Lbs</p>
</li>
<li><i class="fa fa-check"></i>
<p>DO NOT FIT ELEVATORS OR ROOM DOORS.</p>
</li>
<li><i class="fa fa-check"></i>
<p>DO NOT FIT MEDIUM SIZE VANS, REQUIRES A RAMP.</p>
</li>
</ul>
</div>
<div id="field_11_9"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_9">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/STANDARD-WHEELCHAIR-CHECKFRONT.png" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-300.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>Standard Wheelchair is designed to meet the needs of active users. It’s‚ lightweight and easily fits into a Taxi.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Highly durable, enhanced fit and function.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Seat Width: 16 (80-135Lbs), 18 (140 to 195Lbs), 20 (190 to 325Lbs).</p>
</li>
<li><i class="fa fa-check"></i>
<p> Wight 31 Lbs with standard Legrest, elevated leg rest available.</p>
</li>
<li><i class="fa fa-check"></i>
<p>TOP CAPACITY 300lbs.</p>
</li>
</ul>
</div>
<div id="field_11_45"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_45">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/HEAVY-DUTY-WHEELCHAIR-CHECKFRONT.png" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-400.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>HD Wheelchair is designed to meet your needs.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Highly durable, enhanced fit and function.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Weight 31 Lbs with standard Legrest.</p>
</li>
<li><i class="fa fa-check"></i>
<p>TOP CAPACITY 400lbs.</p>
</li>
</ul>
</div>
<div id="field_11_8"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_8">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/EZ-LITE-WHEELCHAIR-ULTRA-PNG-TRANS.png
" alt=""><img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-300.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>The Most Luxuries Powerchair, This Sporty Powerchair Delivers Superior Comfort all Day.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Active-Trac Suspension that makes it as Easy to Enjoy as it is to Use</p>
</li>
<li><i class="fa fa-check"></i>
<p>Weight Capacity of 300 Lbs, with seat size of 18 Inches.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Turning Radius of 20 Inches and Maximum Speed of 4 MPH.</p>
</li>
</ul>
</div>
<div id="field_11_12"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_11_12">
<ul>
<li><img src="https://mexicomobility.com/wp-content/uploads/2022/09/STAND-N-RIDE-CHECKFRONT.png
" alt="">
<img src="https://mexicomobility.com/wp-content/uploads/2022/09/Warning-260-for-non-disabled.png" alt="">
</li>
</ul>
<ul>
<li><i class="fa fa-check"></i>
<p>For NON DISABLED, NON ELDERLY USERS ONLY.</p>
</li>
<li><i class="fa fa-check"></i>
<p>Smooth, Quiet, Non-Intrusive.</p>
</li>
<li><i class="fa fa-check"></i>
<p>15 MPH Top Speed.</p>
</li>
<li><i class="fa fa-check"></i>
<p>20 miles battery range.</p>
</li>
<li><i class="fa fa-check"></i>
<p> Removable Seat for Free Standing operation.</p>
</li>
<li><i class="fa fa-check"></i>
<p>TOP CAPACITY 260lbs.</p>
</li>
</ul>
</div>
</div>
</div>
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<input type="hidden" name="pum_form_popup_id" value="2040">
</form>Text Content
* English
* Español
CLICK THE BLUE ARROW TO SEE OUR MODELS
* TRAVEL SCOOTERS
* Heavy Duty Scooters
* PowerChairs
* WheelChairs
TRAVEL 4 WHEELS SCOOTER
* Key Specs
* Top Speed: 4.25 Mph.
* Weight Capacity: 260 Lbs.
* Weight: 97 Lbs.
STANDARD 4 WHEELS SCOOTER
* Key Specs
* Top Speed: 4.25 Mph.
* Weight Capacity: 325 Lbs.
* Weight: 96 Lbs.
TRAVEL POWER CHAIR
* Key Specs
* Top Speed: 3.50 Mph.
* Battery Charge Distance: 8.00 Miles.
* Weight Capacity: 260 Lbs.
* Weight: 102 Lbs.
FULL SIZE POWER CHAIR
* Key Specs
* Top Speed: 4.00 Mph.
* Battery Charge Distance: 8.95 Miles.
* Weight Capacity: 400 Lbs.
* Weight: 129 Lbs.
MEDIUM SIZE SCOOTER
* Key Specs
* Top Speed: 5.25 Mph
* Weight Capacity: 500 Lbs.
* Weight: 260 Lbs.
FULL SIZE SCOOTER
* Key Specs
* Top Speed: 7.00 Mph.
* Weight Capacity: 500 Lbs.
* Weight: 273 Lbs.
TRANSPORTABLE WHEELCHAIR
* Key Specs
* Weight Capacity: 260 Lbs.
* Weight: 19 Lbs.
STANDARD WHEELCHAIR
* Key Specs
* Quick-Release Axles: No.
* Weight Capacity: 325 Lbs.
* Weight: 41 Lbs.
GET A QUOTE OR RESERVE NOW!
ULTIMATE FORM 3.0 (2024)
1Rental Date and Time
2Select a Scooter, Wheelchair & etc.
3Rental Location
4Profile Information
* Delivery Date*
MM slash DD slash YYYY
Date when Rental Begins. *Minimum rental is 3 Calendar days*
* Return Date*
MM slash DD slash YYYY
Date when Rental Ends. *Minimum rental is 3 Calendar days*
* Tell us What you are looking for?*
IndicateMobility ScooterWheelchairPersonal Transporter Unit (For Non-disabled
ONLY)Rollator / WalkerOxygen ConcentratorCPAP MachineCPAP Supplies
Indicate if you are not a disabled traveler and if you are looking for a
personal transporter device.
* Add an Oxygen Device?*
IndicateYesNo
If yes, you will be ask for more details later in the form.
* City of Service*
Select CityLos Cabos, MexicoCancun, MexicoCozumel, MexicoPuerto Vallarta,
MexicoLa Paz, MexicoLoreto, MexicoMazatlan, MexicoMerida, MexicoPlaya Del
Carmen, Mexico
Indicate First If You'd like to ADD an Oxygen Device or not in order to see
ALL CITIES LISTED.
* Hidden
Number of Days
* NEXT BUTTON WON'T SHOW IF RENTAL IS FOR LESS THAN 3 CALENDAR DAYS!!!!!!.
* User's Weight in Lbs*
Please enter a number from 31 to 600.
Check weight capacity limits. (KgsX2.2=Lbs)
* Describe Your Mobility Disability*
Select oneLimited Walking CapacityElderlyAbsent limb/reduced limb
functionParaplegiaQuadriplegiaHemiplegiaDystrophyOther
* Describe your Mobility Limitation*
Describe your Mobility Limitation - Check all the boxes that describe your
mobility issues.
* Select All
* Age +65 yo
* Bad knees, hips or back
* Can't walk long distances
* Recent Major surgery (less than 2 months)
* Post Stroke Paralysis
* Multiple Sclerosis (MS)
* Lower Limb Paralysis / absent
* Any Motor Disability
* None of the above
* STAND N RIDE NOT RECOMMENDED IF YOU HAVE ANY OF THE LISTED
CONDITIONS/DISABILITIES!
* Select Oxygen Device*
IndicateStationary Oxygen ConcentratorPortable Oxygen ConcentratorCPAP
Machine
*
* Therapy Frequency*
Indicate24 hoursAt NightOccasionally
* Oxygen Rate*
Indicate1-3 lts per minute4-5 lts per minute> 5lts per minuteCPAP without
Oxygen
* CPAP Mask (Nasal)
* CPAP Mask (Nasal)
* *
* Premium Headgear.
* Forehead Cushion: Silicone.
* Gel Cushion: Urethane Gel; EVA.
* Exhalation Elbow and Swivel: Polycarbonate.
* CPAP tubing
* CPAP tubing
* *
* Length: 6 ft (72 in).
* NOT compatible with a machine that requires a 15mm hose.
* Latex Free.
* Diameter: 19mm.
* CPAP Mask + Tubing
* CPAP Mask + Tubing
* *
* Do you Know your CPAP Settings?*
IndicateYesNoI use an AUTO-CPAPNot Sure
* What Pressure your CPAP is set up?*
Indicate4567891011121314
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Does your CPAP has the Ramp setting ON?*
IndicateYesNoI Do not know
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Minutes of Ramp your CPAP is set up?*
Indicate1 minute2 minutes3 minutes4 minutes5 minutes6 minutes7 minutes8
minutes9 minutes10 minutesI Do not know
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Indicate Pressure the Ramp is set?*
Indicate12345678I Do Not Know
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Do you use a Humidifier with your CPAP?*
IndicateYesNoI Do not Know
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Do you use your CPAP with supplemental Oxygen?*
IndicateYesNoI Do not Know
This information is important to set up your device before shipping it to
YOU. If you do not know it, We will set up the CPAP at an average setting
that can Help you while you are abroad.
* Add CPAP Mask?*
IndicateYesNo
* Add CPAP Tubing?*
IndicateYesNo
* Everflo Stationary Oxygen Concentrator
* Everflo Stationary Oxygen Concentrator
* *
* Easy to store, transport, and deliver.
* Interface panel with on/off switch and alarm indicators.
* Recessed flow meter reduces the risk of breakage.
* Metal cannula connector for greater durability.
* Rollator Lite
* Rollator Lite
* *
* Rolling Walker with Seat: Stable, strong and stylish.
* Steel rollator features a durable and supportive frame.
* A comfortable seat, and an under-seat storage pouch.
* Great walker for seniors and adults seeking stability.
* Rollator Heavy Duty
* Rollator Heavy Duty
* *
* Rolling Rollator/Walker with Seat: 500 lbs. weigth Capacity.
* Steel rollator features a durable and supportive frame.
* A comfortable seat, and an under-seat storage pouch.
* Great walker for Heavy seniors and adults seeking stability.
* Rollator-Wheelchair Combo
* Rollator-Wheelchair Combo
* *
* Walker-Wheelchair Combo: Stylish rolling walker with seat combines the
features of a rollator and transport chair in one unit.
* Steel rollator features a durable and supportive frame.
* A comfortable seat, and an under-seat storage pouch.
* Great walker for seniors and adults seeking stability.
* STAND-N-RIDE SCOOTER*
* STAND-N-RIDE SCOOTER
Personal Transporter for NON-DISABLED ADULT USERS ONLY!
* *
* For user's weighting 260 lbs or less ONLY.
* Smooth, Quiet, Non-Intrusive.
* 15 MPH Top Speed.
* 20 miles battery range.
* Removable Seat for Free Standing operation.
* *
Select a STANDARD or HD SCOOTER instead.
* CPAP Machine*
* CPAP Machine
* *
* weighs only a pound and a half.
* Ramp from 4cm up to CPAP pressure
* Altitude Compensation Automatic.
* Dimensions 5.6" x 2.9" x 7.7"
* *
* Premium Headgear.
* Forehead Cushion: Silicone.
* Gel Cushion: Urethane Gel; EVA.
* Exhalation Elbow and Swivel: Polycarbonate.
* *
* Length: 6 ft (72 in).
* NOT compatible with a machine that requires a 15mm hose.
* Latex Free.
* Diameter: 19mm.
* Portable Oxygen Concentrator
* Portable Oxygen Concentrator
* *
* MAX 2 litter per minute in Continous flow.
* FAA aproved.
* Easy Access to Batteries.
* Lightweight less than 10 pounds.
* Standard Wheelchair
* Standard Wheelchair
* *
* Standard Wheelchair is designed to meet the needs of active users. It’s‚
lightweight and easily fits into a Taxi.
* Highly durable, enhanced fit and function with 300 Lbs Capacity. Elevated
leg rest available.
* HD Wheelchair
* HD Wheelchair
* *
* HD Wheelchair is designed to meet your needs.
* Highly durable, enhanced fit and function with 450 Lbs Capacity.
* Weight 31 Lbs with standard Legrest.
* Travel 4 Wheels Scooter
* Travel 4 Wheels Scooter
* *
* 4 Wheel Design Allows for a Highly Maneuverable 34nch Turning Radius, with
260Lbs Capacity
* Top Speed of 4.5 MPH / Range of 12 Miles
* Fully Disassemble to 4 Pieces.
* Heavy Duty Scooter
* Heavy Duty Scooter
* *
* The Stylish , high-performing scooter
* Weight Capacity: 500 Lbs
* Batter Range: 11 Miles.
* Scooter / Batter Weight: 150 / 65 Lbs
* Transport Wheelchair
* Transport Wheelchair
* *
* Ultra Lightweight Transport Chair easily fits into a any Cab or any medium
size car.
* With its attendant operated wheel looks
* Seat Width: 19 x 16 will accommodates someone up to 260 Lbs
* Weight 19 Lbs with Legrest.
* Standard 4 Wheel Scooter
* Standard 4 Wheel Scooter
* *
* Transportable 4 Wheel Scooter
* 4 Wheel Design Allows for Maximum Stability, 40 Inch Turning Radius with
325 Lbs Capacity.
* Top Speed of 4.5 MPH and a Cruising range of 12 Miles.
* Fully Disassemble to 4 Pieces in Matter of Seconds, and Can Easily Fit into
the Trunk of an Car.
* Travel Powerchair
* Travel Powerchair
* *
* The Most Luxuries Powerchair, This Sporty Powerchair Delivers Superior
Comfort all Day.
* Weight Capacity of 325 Lbs, with seat size of 18 Inches.
* SELECT ONE MOBILITY SCOOTER (CLICK THE CIRCLE)
* SELECT ONE WHEELCHAIR (CLICK THE CIRCLE)
* SELECT ONE ROLLATOR (CLICK THE CIRCLE)
* SELECT ONE CONCENTRATOR (CLICK THE CIRCLE)
* SELECT ONE ITEM (CLICK THE CIRCLE)
*
?
* Add a Rollator/Walker?*
IndicateYesNo
*Rolllator rental rates as an ADDON item are reduced compared with as a
primary rental item.
* Choose a Rollator/Walker Type*
SelectRollator LiteRollator Heavy DutyRollator-Wheelchair Combo
*Rolllator lite 260lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight
Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity
* *
* !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Rollator HD instead.
* !!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Rollator HD instead.
* Deliver to*
IndicateHotelHome
* Hotel name*
* Address to Deliver*
Street Address
* Address to Deliver the CPAP Machine*
Street Address State / Province / Region ZIP / Postal Code
This Service is Limited to Mexico.
* Used a Scooter before?*
IndicateYesNo
* How did you find us?*
Select an optionTrip advisorFacebook AdGoogle AdOur Facebook SiteWeb Search
(Random)Returning costumerConcierge or Bell Boy ReferralOther costumer
recommended
* Any special Need?*
IndicateYesNo
* Indicate any special need or concern.*
* I want to:*
SelectPay My Reservation Now!Pay Later (Send me a Quote by E - Mail)
Rental Price is Shown Next Page When "Pay My Reservation Now!" is Selected.
Usually 20% less When Paid Thru Our Website
* Pay With:*
SelectCredit / Debit CardPay Pal
Choose Payment Method
* Renter Name*
First Last
* Phone*
(Country code + Phone number)
* Email*
Enter Email Confirm Email
* Country*
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and
BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia
and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina
FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African
RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo,
Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech
RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl
SalvadorEquatorial
GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth
KoreaSouth
KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana
IslandsOmanPakistanPalauPalestinePanamaPapua New
GuineaParaguayPeruPhilippinesPolandPortugalPuerto
RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and
the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia
and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon
IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan,
SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad
and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab
EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican
CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands,
U.S.YemenZambiaZimbabwe
* YOUR BOOKING BREAKDOWN
* CPAP Mask Quantity*
Price: $175.00 Quantity
**Indicate Quantity
* CPAP Tubing Quantity*
Price: $75.00 Quantity
**Indicate Quantity
* CPAP Mask + Tubing Quantity*
Price: $250.00 Quantity
**Indicate Quantity
* CPAP Mask Quantity*
Price: $175.00 Quantity
**Indicate Quantity
* CPAP Tubing Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Everflo Stationary Oxygen Concentrator Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Everflo Stationary Oxygen Concentrator Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Rollator Lite Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Rollator Heavy Duty Quantity*
Price: $0.00 Quantity
* Rollator-Wheelchair Combo Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* STAND-N-RIDE SCOOTER Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* CPAP Machine Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* CPAP Machine Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Portable Oxygen Concentrator Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Portable Oxygen Concentrator Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Standard Wheelchair Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* HD Wheelchair Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Travel 4 Wheels Scooter Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Heavy Duty Scooter Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Transport Wheelchair Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Standard 4 Wheel Scooter Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Travel Powerchair Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Rollator Lite Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Rollator Heavy Duty Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Rollator-Wheelchair Combo Quantity*
Price: $0.00 Quantity
**Indicate Quantity
* Wheelchair Delivery & Pick up fee*
Price: $0.00
* Scooter Delivery & Pick up fee*
Price: $0.00
* Rollator Delivery & Pick up Fee*
Price: $0.00
* Rollator Delivery & Pick up Fee*
Price: $0.00
* Oxygen Concentrator Delivery & Pick up fee*
Price: $0.00
* Oxygen Concentrator Delivery & Pick up fee*
Price: $0.00
* Portable Oxygen Concentrator Delivery & Pick up fee*
Price: $0.00
* CPAP Machine Delivery & Pick up fee*
Price: $0.00
* CPAP Machine Delivery & Pick up fee*
Price: $0.00
* Stand N Ride Delivery & Pick up Fee*
Price: $0.00
* Supplies Delivery Fee*
Price:
* Rental Total
$0.00
Your Rental Total
* **INDICATE ITEMS QUANTITY
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* Read Terms & Conditions Before Completing Reservation!*
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RENTAL TERMS
OUR TARGET
RENTAL PROCESS
SCOOTER
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TERMS & CONDITIONS
MexicoMobility® Rental Agreement booking terms and conditions.
MexicoMobility® rent to Renter signing this agreement mobility equipment
(scooter, wheelchair or powerchair) subject to all the terms and conditions set
forth in this Rental Agreement and Renter agrees:
1 DEFINITIONS AND GENERAL PRINCIPLES
“You” are the customer (main user) who agree to the terms of the rental
agreement and who is entitled to use the scooter/equipment.
“MexicoMobility®” is the name/DBA of mobility rental company in the rental
agreement.
“Scooter/equipment” is the item that MexicoMobility® is renting to you for the
agreed duration of the rental agreement and will include all parts and
accessories fitted to it at the commencement of the rental.
“Damage” is any damage occurring to the Scooter/equipment (including, lights,
seats, upholstery and any attached accessories).
“Third party” any property, person or organization other than MexicoMobility® or
subsidiary or franchisee named in the rental agreement. .
"scooter/equipment " are any and all items listed on your rental order/invoice
you have rented from MexicoMobility®.
2 PREREQUISITES: WHAT DO YOU NEED IN ORDER TO RENT A SCOOTER OR WHEELCHAIR?
You must hold and be able produce when requested by MexicoMobility® a valid ID
before the rental takes place. The ID must have been issued by authorized
authorities. When the rental booking is made from outside the USA you must also
be able to produce when requested a valid identity card or a valid passport
issued by the country of your residence. You must be aged 21 or over to rent our
mobility equipment. You must produce a valid credit card with an expiry date
after the rental end date. No scooters or equipment can be rented against cash
or check payment unless such payment exceeds the retail value of the scooter or
equipment to be rented.
3 EQUIPMENT/SCOOTER: CONDITION, USE, BREAKDOWN ASSISTANCE AND
MAINTENANCE/MECHANICAL PROBLEMS
3.1 Condition of the scooter/equipment.
Before leaving the rental location, you are required to check the condition of
the equipment. Where an apparent defect is found which is not already noted, you
must immediately inform MexicoMobility® before proceeding with your rental of
the equipment. In such a case, amendments will be made to your rental account at
our office and duly noted by both parties. If a defect is not noted and agreed
prior to proceeding with your rental the condition of the scooter/equipment will
be agreed as being in good order and it will be considered that you received the
scooter/equipment in good order and proper working condition. You will return
the scooter/equipment in the same condition as it was provided at the start of
the rental as agreed. You are responsible for any repair or refurbishment costs
and these costs will be added to the cost of the rental and you agree that these
costs will be charged to your credit/debit card lodged with MexicoMobility®
requiring no additional authorization.
3.2 Use of the scooter/equipment.
The scooter/equipment must not be operated by anyone other than you or a member
of your party over the age of 15. Anyone under the age of 15 will require
written the permission from MexicoMobility®, text or email is acceptable. If you
wish to take the scooter/equipment outside the City of original rental you must
obtainMexicoMobility® prior consent. You must take care of the
scooter/equipment, keep it in good repair and condition, reimburse
MexicoMobility® for any damage to the scooter/equipment, and pay for any costs
incurred. You are liable for all fees, taxes, fines and penalties incurred in
connection with the use of the scooter/equipment and for which MexicoMobility®
is charged, unless they have arisen through the fault of MexicoMobility®. During
the rental period you must carry out the usual checks as would any careful user
and you must take good care and respect the rented scooter/equipment. When
leaving the scooter/equipment unattended even for a short period, you undertake
to secure it in a safe and proper manner. You must use the scooter/equipment in
a responsible manner and in particular, only for the purposes for which it is
intended.
For a scooter, this means primarily carrying one person and their personal items
and not overloading or carrying children. In particular, you must not use the
scooter/equipment under any of the following conditions or for any of the
following purposes:
- operating the scooter or equipment under the influence of alcohol, drugs or
any other type of narcotic substances,
- carrying anything which, because of its smell or condition, harms the Vehicle
or causes MexicoMobility® to lose time or money before it can rent the
scooter/equipment again,
- transportation of animals (with the exception of assistance animals),
- re-rental to or use by other persons,
- carrying passengers
- pushing or towing another vehicle.
- traveling on a surface of which could put the scooter/wheelchairs wheels,
tires or its under body mechanics at risk,
- intentionally committing any offence.
- none of the goods and baggage carried in or on the scooter/wheelchair,
including their packing and stowage equipment, will be permitted to damage the
scooter/wheelchair, nor put the occupants abnormally at risk,
- in any way which breaks the highway Code, road traffic laws or any other laws.
3.3 Maintenance / Mechanical Problems
You must stop the scooter if the instrument panel warning light which is
intended to indicate the existence of a mechanical problem flashes, or if you
become aware of anything else which may indicate the presence of a mechanical
problem with the scooter/equipment.
When the rental starts, the scooter/equipment will be fit for normal use. If it
is not, or if it becomes unfit for normal use during the rental because of
mechanical breakdown or accident, you must inform MexicoMobility® immediately.
MexicoMobility® will have the choice between replacing the scooter/equipment and
repairing the scooter/equipment on site. Any fees and expenses of any repair
undertaken without the order of MexicoMobility® will not be reimbursed to you.
You must inform MexicoMobility®, or one of its agents, of all accidents, damage
to or breakdowns of the scooter/equipment. In any case, neither MexicoMobility®
nor its directors, officers or employees will be liable to you for any loss or
damage (including but not limited to loss of profit or earnings…) nor, to the
extent permitted by the Law, for indirect consequential damages whether your
action is based on contract or in tort. Theft is not available or implied and
you will be liable for replacement. You agree that additional costs will be
charged to your credit/debit card lodged withMexicoMobility® requiring no
additional authorization.
3.4 Breakdown Assistance
For the length of the rental, as agreed with MexicoMobility®, you have the
benefit, at no extra cost, of a Breakdown and Assistance Service. If required,
this service can be contacted by calling the telephone number indicated on the
rental agreement or on the scooter/equipment or on the key fob. In order to
benefit from this cover, you must make contact with MexicoMobility® immediately
after the occurrence of the incident. If you do not contact MexicoMobility® and
if you initiate steps or make any disbursements without the prior consent of
MexicoMobility®, you will not be able to claim for reimbursement of the
expenses.
You agree to waiting period of up to three hours for our technician to attend
your breakdown. This waiting time will vary subject to prevailing traffic
conditions and distances that our technicians will need to travel to attend your
location to enact a repair or exchange of your rented equipment. If you refuse
this service for any reason MexicoMobility® will not be held liable for any loss
you incur or to refund your rental fees as you will have chosen to refuse
service and taken over the control of the situation.
4 RENTAL PERIOD.
4.1 Principle and Calculation.
You undertake to return the scooter/equipment to MexicoMobility® at the agreed
place, on the date and at the time indicated on the rental agreement. The rental
duration is calculated on the basis of days, delivery and return days, are taken
into account as full rental days no matter if a late delivery and early return
was made on customer's request, starting from the time the scooter/equipment is
made available. If you return the scooter/equipment to any other location other
than the agreed location, transportation or repatriation costs will be charged
to you. This includes abandonment for any reason at any location without prior
authorization from MexicoMobility®. You agree that these costs will be charged
to your credit/debit card lodged with MexicoMobility® requiring no additional
authorization.
4.2 Extension of the Original Duration of the Rental
Should you wish to keep the scooter/equipment for a period longer than that
originally set out in the rental agreement, you must first contact
MexicoMobility® at least 48 hours prior to the end of your rental agreement in
order to extend the duration of the rental. Unless otherwise agreed in writing
by MexicoMobility®, once this period is passed, the contracting party remains
liable for additional rental on a single day rate until returned you remain
liable for any damages to MexicoMobility®. You agree that these costs will be
charged to your credit/debit card lodged with MexicoMobility® requiring no
additional authorization.
4.3 Delivery and Collection Terms
MexicoMobility® agrees to deliver and collect the scooter/equipment but you may
have to pay additional charges and follow additional instructions. You must
check at the time of reservation. You must return the scooter/equipment
immediately if MexicoMobility® asks you to do so. In the event that the
scooter/equipment is not delivered to MexicoMobility® upon request you hereby
authorize MexicoMobility® to enter your premises and to do any and all other
things necessary to repossess the scooter/equipment. You will be liable for any
costs associated with such repossession. MexicoMobility® may repossess any
scooter/equipment without notice or liability where MexicoMobility® deems that
such repossession is necessary for its own protection. You agree that any
additional costs incurred will be charged to your credit/debit card lodged with
MexicoMobility® requiring no additional authorization.
4.4 End of Rental
The end of the rental is defined by the return of the scooter/equipment and any
keys and accessories to the MexicoMobility® pick up location as agreed in the
rental agreement. If the scooter/equipment is returned without its key or
accessories you will be charged for the cost of the replacement. Under no
circumstances will MexicoMobility® accept any liability for articles that may
have been left with the scooter/equipment at the end of the rental. You agree
that these costs will be charged to your credit/debit card lodged with
MexicoMobility® requiring no additional authorization.
In some specific cases and Hotels locations and for customer convenience (to use
the scooter up the last minute to be able to reach their shuttle before
departing the Hotel) MexicoMobility®will authorize by the phone or by e mail
that the scooter or wheelchair or any other type of rented equipment is left at
the Concierge or Bell Man area of the Hotel.
5 RATES / TERMS OF PAYMENT
5.1 Rates
The total charges for each rental will be determined according to the price list
applicable at the time of rental and full rental price will be charged at the
time of booking.
5.2 Terms of Payment
When payment is made by means of a credit card, an authorization will be
requested prior to the start of the rental. This authorization will be in place
throughout the rental period to cover any damage or loss of the
scooter/equipment.
At the time of booking the scooter/equipment the invoiced amount will be charged
to the credit/debit card provided. Booking and paying infers your agreement to
MexicoMobility® rental agreement as set before you.
The tariffs applicable to the rental of additional services, items are in force
on the date of issue of the rental agreement, and correspond to the
characteristics you originally indicated at the time of reservation (equipment
type, rental, duration, price, return location…). Any modification in the
characteristics will entail the use of an appropriate alternative tariff. You
agree that any additional costs/charges will be charged to your credit/debit
card lodged with of MexicoMobility® requiring no additional authorization.
6 You will be liable for any damages to MexicoMobility® when renting a scooter
or equipment that has been entrusted to you.
Therefore, in the event of theft of the scooter or equipment or damages caused
to it, you must fully indemnify MexicoMobility® (the indemnification will
include the amounts corresponding to the repair costs, resale value of the
scooter or equipment, loss of use, administration charges…). The amount will not
exceed the market value of the rented scooter or equipment at the time of the
event. This liability may be reduced if you opted for the accidental damage
waiver insurance.
Therefore, at the end of the Rental, IN THE EVENT OF DAMAGE OR THEFT, YOU WILL
BE DEBITED THE FULL AMOUNT FROM THE CREDIT/DEBIT CARD USED AT THE TIME OF
BOOKING. If this is not possible the full amount will be billed to you for
immediate payment.
If you fail to take reasonable measures for the safety of the scooter/equipment,
its parts or accessories, or fail to comply with all restrictions on the use of
the scooter/equipment or otherwise abuse or misuse it and you incurr on any
thirda party damage or injury you will be liable indemnify the third party.
You will not be exempt from liability towards MexicoMobility® in the case of
breach of contract. Therefore, you will be responsible for any financial loss
MexicoMobility® suffers as a result of such breach and for any relevant claims
made by other people. You agree to pay any amounts MexicoMobility® spends in
enforcing these terms.
THEREFORE IN ANY CASE, NEITHER MexicoMobility® NOR ITS OFFICERS, DIRECTORS,
EMPLOYEES WILL BE LIABLE TO THE CONTRACTING PARTY FOR ANY AMOUNTS NOR FOR ANY
ACTIONS, LAW SUITS OR CLAIMS RELATED TO ANY DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE DAMAGES (SUCH AS LOSS OF BUSINESS, LOSS OF PROFIT) ARISING OUT OF OR IN
CONNECTION WITH THE RENTAL OR THE USE OF ANY SCOOTER OR EQUIPMENT WHETHER THE
ACTION IS BASED ON CONTRACT OR IN TORT. YOU WILL INDEMNIFY AND HOLD
MexicoMobility® HARMLESS FROM ALL CLAIMS, LIABILITIES, DAMAGES, LOSSES OR
EXPENSES ARISING OUT OF THE RENTAL AND/OR THE USE OF THE SCOOTER OR EQUIPMENT.
If the loss suffered by MexicoMobility® is subsequently reduced (recovery of the
scooter or equipment within 7 days, partial or total liability on the part of
the Third party), you will receive the corresponding reimbursement.
6 DAMAGE
6.1 Damage
Both at Delivery and Return MexicoMobility® together with you will record all
visible damage to the scooter/equipment which you hereby acknowledge. Existing
damage will be noted. At the end of the rental the identification of any new
damage must be added to your rental account. Any new damage will be immediately
noted by MexicoMobility®.
Any and all repair costs will be directly billed to you by MexicoMobility® and
will include the cost of the damage repair as well as administration charges,
immobilization costs, spare parts and labor costs. The above-mentioned invoiced
repair costs are payable under the same conditions as for the payment of the
rental agreement and you agree that these costs will be charged to your
credit/debit card lodged with MexicoMobility® requiring no additional
authorization.
7 CANCELLATION (NEW POLICY EFFECTIVE FOR RENTALS PAID AFTER SEPTEMBER 2020)
Rentals cancelled for ANY reason up to 3 calendar days prior to delivery date
will be refunded the total equipment rental amount paid, minus the credit card
(VISA / MC) processing fees of 6%. If the cancellation occurs within 3 calendar
days of the delivery date (requested day by customer) , the complete cost of the
equipment rental is NON-REFUNDABLE. All orders subject to a promo code, discount
or special offer ARE NON- REFUNDABLE without consideration of the above period
of time.
Rentals canceled after your scooter/equipment is delivered or is out for
delivery will not be refunded in any part whatsoever.
MexicoMobility® Cancellation Policy is purely based on time. Therefore, ANY
request of Cancellation and Refund within the 3 calendar days before the
Delivery Date due to Health Issues, Injuries, Accidents, or any other critical
situation or condition that customer might believe is a reason for Cancelling,
the RENTAL will not be refunded in any part whatsoever.
NEITHER MexicoMobility® NOR ITS OFFICERS, DIRECTORS, EMPLOYEES WILL BE LIABLE
for any wheelchair/Scooter/Powerchair inaccessible Hotels, Facilities,
Destinations, Streets, Locations or ANY area whatsoever the customer decided to
rent and use the equipment. In the Case the customer finds out the use of the
equipment is not possible due to inaccesible facilites or location and decides
to return the equipment before the paid return day or to not receive it at
delivery, the RENTAL will not be refunded in any part whatsoever.
Lifting and/or loading scooters/equipment
Caution is advised when lifting or loading any of our equipment to include but
not restricted to loading in and out of vehicles. This includes items such as
batteries and scooter parts which are also heavy. Anyone attempting to lift any
of our equipment should at all times adopt correct lifting practices to prevent
injury, loss or damage. MexicoMobility® cannot accept and responsibility for
injury, loss or damage caused by the incorrect lifting or loading of any of our
equipment. We advise that at all times you have someone to assist you when
lifting or loading our equipment and you do not attempt any lifting or loading
if you are unsure you are fully able to do so.
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MexicoMobility®️ We rent scooters, wheelchairs, powerchair & oxygen equipment to
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#puertovallarta #mazatlan #playadelcarmen #merida #cozumel #mexicoaccesible
#mexicomobility #forhandicappedtravelers#electricscooters#mobilityscooters
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#travelwithwheelchair #travelingwithdisabilities #travelwithwheels
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MexicoMobility®️ We rent scooters, wheelchairs, powerchair & oxygen equipment to
all hotels & villas in major Mexico Beach destinations. #cabo #cancun
#puertovallarta #mazatlan #playadelcarmen #merida #cozumel #mexicoaccesible
#mexicomobility #forhandicappedtravelers#electricscooters#mobilityscooters
#wheelchairaccessiblehotels #wheelchairaccessible #wheelchairs
#travelwithwheelchair #travelingwithdisabilities #travelwithwheels
#disabledtraveler
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MexicoMobility®️ We rent scooters, wheelchairs, powerchair & oxygen equipment to
all hotels & villas in major Mexico Beach destinations. #cabo #cancun
#puertovallarta #mazatlan #playadelcarmen #merida #cozumel #mexicoaccesible
#mexicomobility #forhandicappedtravelers#electricscooters#mobilityscooters
#wheelchairaccessiblehotels #wheelchairaccessible #wheelchairs
#travelwithwheelchair #travelingwithdisabilities #travelwithwheels
#disabledtraveler
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MexicoMobility®️ We rent scooters, wheelchairs, powerchair & oxygen equipment to
all hotels & villas in major Mexico Beach destinations. #cabo #cancun
#puertovallarta #mazatlan #playadelcarmen #merida #cozumel #mexicoaccesible
#mexicomobility #forhandicappedtravelers#electricscooters#mobilityscooters
#wheelchairaccessiblehotels #wheelchairaccessible #wheelchairs
#travelwithwheelchair #travelingwithdisabilities #travelwithwheels
#disabledtraveler
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MexicoMobility®️ We rent scooters, wheelchairs, powerchair & oxygen equipment to
all hotels & villas in major Mexico Beach destinations. #cabo #cancun
#puertovallarta #mazatlan #playadelcarmen #merida #cozumel #mexicoaccesible
#mexicomobility #forhandicappedtravelers#electricscooters#mobilityscooters
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Copyright 2005-2024, MexicoMobility®. Call Now! 833-744-9444. Fast booking
Here!.
ULTIMATE FAST BOOKING-(1.0)
Select the Equipment you need, rental dates and pay now!
Hidden
Number of Days
Choose a Different Type of Equipment(Required)
SelectMobility ScootersManual or Electric WheelchairsRollators/WalkersOxygen
Concentrator / CPAP
Choose the equipment type you need.
START BY PICKING YOUR RENTAL DATES
Minimum Rental Length is 3 Calendar days.
Delivery Date(Required)
MM slash DD slash YYYY
Date when Rental Begins. *Minimum rental is 3 Calendar days*
Return Date(Required)
MM slash DD slash YYYY
Date when Rental Ends. *Minimum rental is 3 Calendar days*
Select your Scooter(Required)
***Click the scooter Button to compare price and see a picture
Travel Scooter
Standard Scooter
Heavy Duty Scooter
Scooter User's Weight in Lbs(Required)
Check weight capacity limits. (KgsX2.2=Lbs)
!!!!!!Minimum Rental Length is 3 Calendar days. Adjust dates to Enable "Next
Button"
3 CALENDAR DAYS RENTAL SAMPLE (MINIMUM LENGTH).
Travel 4 Wheels Scooter(Required)
Price: $0.00
*Price per day
Travel Scooter Qty(Required)
Please enter a number from 1 to 4.
**Indicate Quantity
Travel Scooter Delivery & Pick up fee(Required)
Price: $0.00
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
Rental Total - Travel Scooter(Required)
**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.
YOUR TOTAL BREAKDOWN - SCOOTER RENTAL
*Select Quantity to Calculate your Total **Rental total include Taxes and
Delivery/Pickup
Travel 4 Wheels Scooter Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Travel Scooter Delivery & Pick up fee(Required)
Price: $0.00
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
Rental Total - Travel Scooter(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE!!!!. Select a Standard Scooter instead.
Standard 4 Wheel Scooter Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
Standard Scooter Delivery & Pick up fee
Price: $0.00
4 Wheel Scooter - 325Lbs Lbs Weight Capacity - Fully Disassembles to 4 Pieces.
Rental Total - Standard Scooter(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.
Heavy Duty Scooter Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
HD Scooter Delivery & Pick up fee
Price: $0.00
Stylish and high-performing scooter. Weight Capacity: 500 Lbs. Batter Range: 11
Miles. Scooter total weight 150.
Rental Total - HD Scooter(Required)
*Taxes & Delivery/Pick up Incl.
Hidden
WHEELCHAIRS
Choose a Wheelchair Type(Required)
ChooseStandard WheelchairTransport WheelchairHeavy Duty WheelchairElectric
(Travel Powerchair)
Weight Capacity *Standard Wheelchair 300lbs. ** Heavy Duty Wheelchair 500lbs.
***Electric Wheelchair 250lbs. ****Transport Wheelchair 250 lbs
Wheelchair User's Weight in Lbs(Required)
Check weight capacity limits. (KgsX2.2=Lbs)
*
Standard Wheelchair(Required)
Price: $0.00
*Price Per Day
Standard Wheelchair Qty(Required)
Please enter a number from 1 to 4.
Standard Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
4 Portable-Folds-300lbs capacity.
Rental Total(Required)
**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.
YOUR TOTAL BREAKDOWN - WHEELCHAIR RENTAL
*Select Quantity to Calculate your Total **Rental total include Taxes and
Delivery/Pickup
Standard Wheelchair Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Standard Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
4 Portable-Folds-300lbs capacity.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.
Hidden
TRANSPORT WC
Transport Wheelchair Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Transport Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
4 The smaller option, more portability than comfort-260 lbs weight capacity.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE, CHOOSE EITHER A STANDARD OR HD
WHEELCHAIR!!!!.
Hidden
HD WHEELCHAIR
Heavy Duty Wheelchair Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
HD Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
4 Resistant and comfortable-Up to 500 lbs capacity. Heavy but portable
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
Hidden
ELECTRIC WHEELCHAIR
Electric Wheelchair (Travel Powerchair) Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Electric Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
4 Electric - Folds - Portable-Joystick operated-260 lbs capacity.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.
Hidden
ROLLATORS
Choose a Rollator/Walker Type(Required)
Rollator Lite
Rollator Heavy Duty
Rollator-Wheelchair Combo
*Rolllator lite 300lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight
Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity
Rollator User's Weight in Lbs(Required)
Please enter a number from 31 to 600.
Check weight capacity limits. (KgsX2.2=Lbs)
*
Rollator Lite(Required)
Price: $0.00
*Price Per Day
Rollator Lite Qty(Required)
Please enter a number from 1 to 4.
Rollator Lite Delivery & Pick up fee(Required)
Price: $0.00
4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and
an under-seat storage pouch.
Rental Total(Required)
**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.
YOUR TOTAL BREAKDOWN - ROLLATOR RENTAL
*Select Quantity to Calculate your Total **Rental total include Taxes and
Delivery/Pickup
Rollator Lite Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Rollator Lite Delivery & Pick up fee(Required)
Price: $0.00
4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and
an under-seat storage pouch.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
!!!!!!USER's WEIGHT NOT COMPATIBLE! SELECT A ROLLATOR HEAVY DUTY.
Rollator Heavy Duty Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Rollator HD Delivery & Pick up fee(Required)
Price: $0.00
4 Rolling Walker with Seat: 500 lbs. Weigth Capacity. A comfortable seat, and an
under-seat storage pouch.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
Rollator-Wheelchair Dual Unit Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Rollator-Wheelchair Dual Unit Delivery & Pick up fee(Required)
Price: $0.00
4 Walker-Wheelchair dual unit: Stylish rolling walker with seat combines the
features of a R Rollator and transport chair in one unit.
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
Hidden
OXYGEN CONCENTRATORS
Select an Oxygen Device(Required)
Stationary Oxygen Concentrator
Portable Oxygen Concentrator
CPAP Machine
Stationary Oxygen Concentrator(Required)
Price: $0.00
*Indicate Quantity
Stationary Oxygen Concentrator Qty(Required)
Please enter a number from 1 to 4.
Oxygen Concentrator Delivery & Pick up fee(Required)
Price: $0.00
Rental Total(Required)
**Indicate Quantity to Calculate Rental Total. Taxes & Delivery/Pick up Incl.
Stationary Oxygen Concentrator Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Oxygen Concentrator Delivery & Pick up fee(Required)
Price: $0.00
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
Portable Oxygen Concentrator Quantity(Required)
Price: $0.00
Quantity
*Indicate Quantity
Portable Oxygen Concentrator Delivery & Pick up fee(Required)
Price: $0.00
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
CPAP Machine Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
CPAP Machine Delivery & Pick up fee(Required)
Price: $0.00
Rental Total(Required)
*Taxes & Delivery/Pick up Incl.
Next Button Enables Once a 3 day length or Longer Rental Period is Chosen.
City of Service(Required)
Select CityLos Cabos, MexicoCancun, MexicoCozumel, MexicoPuerto Vallarta,
MexicoLa Paz, MexicoLoreto, MexicoMazatlan, MexicoMerida, MexicoPlaya Del
Carmen, Mexico
Choose your rental destination. If not listed, then we cannot provide your
rental.
Describe Your Mobility Disability(Required)
SelectLimited Walking CapacityElderlyAbsent limb/reduced limb
functionParaplegiaQuadriplegiaHemiplegiaDystrophyOther
This information Help us to assign the best equipment to fullfil your needs
Have you used a Scooter/Powerchair before?(Required)
SelectYesNo
Add an Oxygen Device?(Required)
IndicateYesNo
If yes, you will be ask for more details later in the form.
Select an Oxygen Device(Required)
Stationary Oxygen Concentrator
Portable Oxygen Concentrator
CPAP Machine
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
Stationary Oxygen Concentrator Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
Portable Oxygen Concentrator Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
CPAP Machine Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
Add a CPAP Nasal Mask?(Required)
IndicateYesNo
AVAILABLE NASAL MASKS ONLY
CPAP Nasal Mask with Headgear Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
Add a CPAP Tubing?(Required)
IndicateYesNo
***If your tube has a heating device, you ll need a standard tubing****
4 Wheel - 250 lbs Weight Capacity -Fully Disassembles to 4 Pieces.
CPAP Tubing Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
Hidden
STAND-N-RIDE SCOOTER(Required)
STAND-N-RIDE SCOOTER
Personal Transporter for NON-DISABLED ADULT USERS ONLY!
*
* For user's weighting 260 lbs or less ONLY. Smooth, Quiet, Non-Intrusive. 15
MPH Top Speed. 20 miles battery range. Removable Seat for Free Standing
operation.
Deliver to(Required)
Select PlaceHotelHome
Hotel name(Required)
Address to Deliver(Required)
Street Address
How did you find us?(Required)
Select an optionTrip advisorFacebook AdGoogle AdOur Facebook SiteWeb Search
(Random)Returning costumerConcierge or Bell Boy ReferralOther costumer
recommended
Any special Need?(Required)
IndicateYesNo
Indicate any special need or concern.(Required)
Add a Rollator/Walker?(Required)
IndicateYesNo
*Rollator rental rates as an ADDON item are reduced compared with as a primary
rental item.
Pay With:(Required)
SelectCredit / Debit CardPay Pal
Choose Payment Method
Choose a Rollator/Walker Type(Required)
ChooseRollator LiteRollator Heavy DutyRollator-Wheelchair Combo
*Rolllator lite 300lbs. Weight Capacity ** Rolator Heavy Duty 500lbs. Weight
Capacity ***Rollator-Wheelchair 300lbs. Weight Capacity
*
4 Rolling Walker with Seat: Stable, strong and stylish. A comfortable seat, and
an under-seat storage pouch.
Rollator Lite Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
!!!!!!USER's WEIGHT NOT COMPATIBLE, CHOOSE A ROLLATOR HD!!!!.
4 Rolling Walker with Seat: 500 lbs. Weigth Capacity. A comfortable seat, and an
under-seat storage pouch.
Rollator Heavy Duty Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
4 Walker-Wheelchair dual unit: Stylish rolling walker with seat combines the
features of a R Rollator and transport chair in one unit.
Rollator-Wheelchair Dual Unit Quantity(Required)
Price: $0.00
Quantity
**Indicate Quantity
!!!!!!USER's WEIGHT NOT COMPATIBLE!!!!.
Renter Name(Required)
First Last
Phone(Required)
(Country code + Phone number)
Email(Required)
Enter Email Confirm Email
Country(Required)
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and
BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia
and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina
FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African
RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo,
Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech
RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl
SalvadorEquatorial
GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth
KoreaSouth
KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana
IslandsOmanPakistanPalauPalestinePanamaPapua New
GuineaParaguayPeruPhilippinesPolandPortugalPuerto
RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and
the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and
MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon
IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan,
SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad
and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited
KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin
Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe
Rollator Lite Delivery & Pick up fee(Required)
Price: $0.00
Rollator HD Delivery & Pick up fee(Required)
Price: $0.00
Rollator-Wheelchair Delivery & Pick up fee(Required)
Price: $0.00
Portable Oxygen Concentrator Delivery & Pick up fee(Required)
Price: $0.00
Oxygen Concentrator Delivery & Pick up fee
Price: $0.00
CPAP Delivery & Pick up fee(Required)
Price: $0.00
Rental Total
Total in USD, Taxes, Delivery & Pick up incl.
Credit / Debit Card(Required)
Read Terms & Conditions Before Completing Reservation!(Required)
I agree to the
Terms and Conditions
| Privacy Policy
READ Cancellation Policy!
×
Read Terms & Cancellation Policy
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MOBILITY SELECTOR
Select User's Weight(Required)
<260 lbs (<120 kgs)
261-340 lbs (120 - 160 kgs)
>340 lbs (>160 kgs)
Some ITEMS are shown or hidden based on Equipment Weight Capacity for best
performance.
Select your Mobility Equipment(Required)
Select EquipmentTravel ScooterStandard ScooterHD (Medium) ScooterHD (Full size)
ScooterStandard WheelchairHeavy Duty WheelchairPowerchairStand N Ride (Non
disabled ONLY)
Important: Check Unit Weight Capacity to choose the right one for you and have
its best performance.
Is the User Elderly or Disabled?(Required)
YesNo
The Stand N Ride scooter is FOR NON DISABLED NON ELEDERLY USERS ONLY. Otherwise
the risk of falling is very high.
*
* 4 Wheels Design Allows for a Highly Maneuverable 34nch Turning Radius
* Top Speed of 4.5 MPH / Range of 12 Miles
* Fully Disassemble to 4 Pieces.
* TOP WEIGHT CAPACITY 260 lbs.
*
* Transportable 4 Wheel Scooter
* 4 Wheel Design Allows for Maximum Stability, 40 Inch Turning Radius.
* Top Speed of 4.5 MPH and a Cruising range of 12 Miles.
* Fully Disassemble to 4 Pieces in Matter of Seconds, and Can Easily Fit into
the Trunk of an Car.
* TOP WEIGHT CAPACITY 325 lbs.
*
* The Stylish , high-performing scooter
* TOP Weight Capacity: 500 Lbs
* Batter Range: 11 Miles.
* Scooter / Batter Weight: 150 / 65 Lbs
* FITS ELEVATORS AND ROOM DOORS.
* FITS MEDIUM SIZE VANS.
*
* The Stylish , high-performing scooter
* Weight Capacity: 500 Lbs
* Batter Range: 11 Miles.
* Scooter / Batter Weight: 150 / 65 Lbs
* DO NOT FIT ELEVATORS OR ROOM DOORS.
* DO NOT FIT MEDIUM SIZE VANS, REQUIRES A RAMP.
*
* Standard Wheelchair is designed to meet the needs of active users. It’s‚
lightweight and easily fits into a Taxi.
* Highly durable, enhanced fit and function.
* Seat Width: 16 (80-135Lbs), 18 (140 to 195Lbs), 20 (190 to 325Lbs).
* Wight 31 Lbs with standard Legrest, elevated leg rest available.
* TOP CAPACITY 300lbs.
*
* HD Wheelchair is designed to meet your needs.
* Highly durable, enhanced fit and function.
* Weight 31 Lbs with standard Legrest.
* TOP CAPACITY 400lbs.
*
* The Most Luxuries Powerchair, This Sporty Powerchair Delivers Superior
Comfort all Day.
* Active-Trac Suspension that makes it as Easy to Enjoy as it is to Use
* Weight Capacity of 300 Lbs, with seat size of 18 Inches.
* Turning Radius of 20 Inches and Maximum Speed of 4 MPH.
*
* For NON DISABLED, NON ELDERLY USERS ONLY.
* Smooth, Quiet, Non-Intrusive.
* 15 MPH Top Speed.
* 20 miles battery range.
* Removable Seat for Free Standing operation.
* TOP CAPACITY 260lbs.
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