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Loan Closet Equipment Reservation Request
This page is for use by ALS patients/caregivers to request reservation of an inventory item.
*
Indicates information that must be provided before submitting request.
For ease of entry, you may simply copy and paste the desired item from previous page list.
*
Indicates required field
Patient Name
*
ALS Clinic
*
Request Submitted By:
*
Phone Number
*
Email
*
Item Description
*
Enter item description as shown on inventory listing.
** Note: Selected items may require Clinic approval before issuance. If the item you are requesting falls into that category, we will notify you. As such, delivery time may be delayed as necessary to obtain required approval.
Date Needed By
*
Indicate the date the item is needed by.
Indicate Delivery Preference
*
I will pick it up
Need item Delivered
Other (add details below)
Note: Please contact our offices to arrange date that item is to be picked up or for delivery details.
Additional Information
*
Submit
Home
About Us
What is ALS?
Our Staff
Board of Directors
Contact Us
Our story through videos
Testimonials
Survey
Partners
FAQs
Support Services
ALS Clinics
Support Groups
Respite Services
Educational Seminars
Jim's Voice
MyTurn Project Fund
>
Grant information and application
Loan Closet
>
Inventory
Home Visits
ALS Connections
Caregiver Training
Events
Golf Event
Grand Rapids PedALS 2019
Third Party Events
Store
Susan Mast Apparel
Bracelets
Joe's Brother Coffee
Donate
#GivingTuesday 2019
Tribute Donation
MyTurn Project Donation
I HATE ALS Donation
General Donation
Volunteer
Wish List
>
Fulfilled Wishes