* Your Full Name

    * Email

    * Phone Number

    Each Oxygen Rental comes with 3 FREE Nasal Cannulas, a 7 foot extension with splitter and humidifier. You may order additional nasal cannulas below.


    Number Of Units

    Number Of Days/Weeks

    Daily Rental Rate Per Oxygen Unit $80.00/day

    Special 5-7 Day Rate Per Oxygen Concentrator Unit $350.00/week

    Rental Rate Per Portable Cylinder Unit $45/day (minimum 2 day)

    Additional Nose Cannulas Pieces At $3.00 Each:


    Guest Information

    * Hotel, Condominium, or Address:

    * Guest Name:

    Phone Number in Telluride (If known):

    Reservation Agency If Applicable:

    * Phone Number - Your Cell:

    Estimated Delivery Date And Time:

    Estimated O2 Unit Return Date:

    * I authorize RockyMountainAire to receive payment for services rendered using the following option:

    I would like to tip the delivery person Other $:

    * Initials (Required for Web Submission):

    "By Signing/Initialing above I am authorizing charges to my credit card, for Oxygen Rental Services. I understand my Credit Card will be billed for the total number of days multiplied by the total number of units rented, as specified above, after Oxygen Units are returned or Pick Up is arranged".

    Credit Card Information

    * Name as it appears on card:

    * Billing Address Street:

    * City:

    * State:

    * Zip:

    * Type of Card:

    * Credit Card Number:

    * Expiration Date:

    Month: Year:

    * CVV text (Security Code):

    Special Instructions, Questions, etc:

    We recommend you print this page for your records before submitting!