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Ameda Elite 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


Name:

Note: Address must be the same zip code as the billing address of the credit card.
Street Address:

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 of Rental:

___one mo pump rental $65

___three mo rental $165

___five mo rental $225

Choose accessory option below (required):

___I already have an Ameda personal hygiene double pumping kit.

___Double pumping collection kit $44.99

___Cooler carrier bag with blue ice $44.99

___Spare parts kit (2 tubing, 4 valves and 2 diaphragms) $27.99

___M/L CustomFit Breast Flange Pair (28.5/30.5 mm) $14.99

___
XL/XXL CustomFit Breast Flange Pair (32.5/36.0 mm) $14.99

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 $45-$65 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 UPS 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 UPS 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.