Apply for Equipment

Thank you for connecting with Assist ME

We aim to be “The Mobility Resource for Charlotte-Area Residents in Need.”

Assist ME recycles gently used equipment donated by people in the community. Our goal is to help people who do not have medical insurance or the money to pay for the equipment they need.

If we do not have the equipment you need, we may not be able to help, but we will do our best to meet your need. Before accepting any equipment from Assist ME, please check with your church, family, and friends.

All items are gifted to recipients based on income and medical need.

Applicants must assume all responsibility for the equipment, including its proper maintenance and use.

Fill the Form Below

First Name

Last Name

Applicant's Email

Applicant's Phone Number

Employment Status

Other Employment Status

Applicant's Street Address

Applicant's City

Applicant's State

Applicant's Zip Code

Applicant's Date of Birth

Applicant's Gender

Applicant's Race

Applicant's Household Monthly Income

Number of People Living in Household

Applicant's Health Insurance

Applicant's Height

Applicant's Weight

Applicant's Current Location

Other Location

Applicant's Discharge Date

Please Select Medical Diagnosis

Other Equipment Needed

In the last 30 days, how many times have you fallen?

In the last 30 days, how many times have you been admitted to the ER?

What activities will this equipment help Applicant accomplish?

Without this equipment, will you have to change your residence?

Title of Referring Medical Professional

Employer of Medical Professional

Name of Referring Medical Professional

Phone Number of Referring Medical Professional

Email of Referring Medical Professional

TERMS of SERVICE: The applicant understands that filling out this request does not guarantee they will receive the equipment.

Yes No

TERMS of SERVICE: Assist ME provides all equipment to you in an as-is condition. Assist ME makes no representations or warranties, express or implied, concerning the equipment, including its fitness for a particular purpose or its condition. At the time you pick up the equipment, you will have the opportunity to inspect the equipment’s condition for any defects, issues, and/or problems. YOU AGREE THAT BY ACCEPTING THE EQUIPMENT, YOU ARE ACCEPTING THE EQUIPMENT IN ITS AS-IS CONDITION, INCLUDING ANY FAULTS OR DEFECTS THAT MAY BE PRESENT IN THE EQUIPMENT.

Yes No

TERMS of SERVICE: By accepting the equipment, you further agree to accept all responsibility for the equipment. You agree to waive all claims, liabilities, remedies (at law or in equity), damages, and/or causes of action that you may have against Assist ME, including its past and present owners, members, officers, directors, employees, agents, and/or representatives (“Released Parties”) related to the use of the equipment, including any injuries that may result from the use of the equipment. You further covenant not to sue any of the Released Parties related to the use of the equipment, including any injuries that may result from the use of the equipment.

Yes No

TERMS of SERVICE: The applicant gives the Assist ME organization permission to review their medical records and get any information needed from the doctor to justify the need for the requested equipment.

Yes No

TERMS of SERVICE: By accepting the equipment and removing the equipment from the pick-up location, you agree to the above terms and conditions. If you do not accept the above terms and conditions, leave the equipment at the pick-up location.

Yes No

Applicant's Signature - The applicant should complete their first and last name as their digital signature to certify they understand the above Terms of Service.

Who will pickup Requested Equipment? - If this request is approved and we have the needed medical equipment, you will receive a confirmation email with details on where and when to pick up the equipment. Items are held for 3 days from the time that the confirmation email is sent.

Will you return gently used medical equipment when you no longer need it so that it can be helpful to someone else in need?

Yes No

Our services are charity-based. Would you consider a donation of $5 or more? Donate

Yes No

Call Us

704-659-1123

Email Us

receptionist@assistmenc.com

Visit Us

Atrium Myers Park Clinic

1350 S Kings Dr. | Charlotte, NC