Borrow Equipment Form

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Please fill out the form below to borrow equipment, we will get back to you as soon as we can to take the next step.

    * = Required.

    Parent or Legal Guardian Contact Information

    Parent or Legal Guardian Address

    County of Residence for Parent or Legal Guardian

    Child Information

    Adaptive Equipment to Borrow

    important Note: Your Therapist PT/OT/Speech MUST help with fitting and instructing you in the use of this equipment. COLE does not help with instruction or fitting of equipment.

    Misc. Questions

    Did you try to get this equipment through insurance or other funding source?

    What is your insurance type?

    How did you hear about us?

    Comments or Other Information