loaner request form


To request a FREE complimentary loaner while yours is in service, please complete the following Loaner Request Form below.

For immediate assistance in processing your Loaner Request, please contact us (888) 799-CANI (2264). 

Name *
Name
Address
Address
Phone
Phone
Please indicate the best phone number to reach you with loaner details, availability and confirmation.
Please indicate the Make of the Device you are requesting a loaner for.
Please indicate the Model of the Device you are requesting a loaner for
Please indicate the Serial # of the Device you are requesting a loaner for.
Please indicate any notes, comments, and/or special instructions for your loaner request.