Hospital Grade Breast Pump Rental Agreement
In order to rent a breast pump, print this page, complete 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
Street Address (Must be the same zip code as the billing address of the credit card):
City: State: Zip:
Drivers License State: Number:
Credit Card #:
Exp. Date:________ CVV Code:________
Secondary Phone# (work/mobile/spouse):
Choose Breast Pump Brand/Model:
___First Available (Save $5 per month.)
Specify Length of Rental:
___one mo pump rental $60
___three mo rental $135
___five mo rental $200
Choose accessory option below (required):
___Double pumping collection kit $44.99
___Cooler carrier bag with blue ice $34.99
___I already have a personal hygiene pumping kit. Circle brand: Ameda Medela Hygeia
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 $40-$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 pump is not cleaned before returning. $25 shipping fee will be added to orders for this pump. 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.