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Baby Scale Rental Agreement

In order to rent a baby scale, print this page, complete the form and fax the signed copy to 877-909-7867 or mail to: Lactation Connection PO Box 265 Bluff Dale, TX 76433.  Questions?  Call 800-216-8151

Complete Personal Information

Name:

Street Address (Must be the same zip code as the billing address on the credit card): 
 

City:                                                  State:                                       Zip:

Drivers License State:          Number:                                       

DOB:

Email Address:    

Credit Card #:  

Exp. Date:________ CVV Code:________ 

Primary Phone#:                                        

Secondary Phone# (work/mobile/spouse):
 

Specify Length/Type of Rental:
Standard scales weigh in .5 oz or 20 gram
increments.  Premium scales weigh in .18 oz or 5 gram increments and have memory function. 

___one month standard scale rental $35

___one month premium scale rental with memory $45  

___two months standard scale rental $60   

___two months premium scale rental with memory $80  

Choose Sales Tax Option Below:

___My billing/shipping address is outside Texas - Sales Tax is not applicable.       

___I live in TX, but I am having my doctor fax an RX for the breast pump to 877-909-7867 to avoid the sales tax.

___I am inside TX and do not want to send an RX - I understand 6.75% sales tax will be added.

By signing below, I agree that the information provided is true and accurate and that I accept responsibility for the whereabouts of the equipment rented as well as the charges to my credit card for the initial rental $35-$60 per month thereafter.  This rate is calculated by prorating the term of the initial rental.  I understand that this is a contract for the full term of the rental and that no refunds will be given for early return.  I further understand that I will be charged a $10 cleaning fee if my scale is not cleaned before returning.  $25 shipping fee will be added to orders for this scale.  This will cover FedEx ground shipping and a label for return shipping upon your request as well as shipping insurance.  Terms of rentals will begin 1 day after ship date to allow for rental to arrive.  Returns are considered on-time if scanned by FedEx on or before the date due.

Signature of lessee/cardholder:
 
__________________________________________

NOTE:  If you do not wish to mail or fax, you can scan and email your form.  Please call 800-216-8151 for email.