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Equipment Rental Form

Radio$35.00 - Blood Pressure Cuff$15.00 - Haakaa$25.00 - Lansinoh Manual Pump$160.00 - Electric Breast PumpRecurs monthly starting in 25 days for 1 period

Payer Details

Name *

Email *

Renter Name *

Equipment name and # *

Return date (14 days) *

Employee Witness Initials *

Rental agreement: Dar a Luz Birth & Health Center (DAL) rents to the Renter signing this agreement medical equipment (blood pressure cuff or breast pump) subject to all the terms set forth in this Rental Agreement and Renter agrees: Renter is a major credit card holder and a DAL client, or immediate family member of a DAL client. The medical equipment is the property of DAL and is in good condition. Renter shall return the equipment to DAL in the same condition as when received, with all the same equipment and attachments, at the end of the rental period for inspection, or sooner, or upon demand by DAL. DAL shall not be liable or responsible for the loss or damage to any rental property left, lost, damaged, stolen, stored or transported by Renter, their agents, servants, or employers, or any other person using the medical equipment, either before or after the return thereof to DAL. The Renter agrees to hold DAL harmless (including its agents, officers, servants, and employees) from and against any and all damages, injuries, demands actions and causes of action whatsoever arising out of or related to any loss, damage or injury claimed by persons arising from the use of the medical equipment, provided that such loss or damage was not caused by fault, gross negligence, and willful misconduct of DAL or its employees. I agree to be financially responsible for the equipment I am renting. I agree to return it by the due date above or to contact DAL before that date to extend my rental period for another 14 days, at DAL’s discretion. I have reviewed and accepted the conditions outlined above. I understand and authorize DAL to charge my credit card for any repair or replacement costs that DAL deems necessary up to and including the amount above plus reasonable collection fees. I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form.

Total

$

Credit / Debit Card *