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Baby Scale Rentals...anywhere in the continental USA!  Simply fill in the information on this form, print it out,  and fax the signed copy to 877-909-7867 or mail form to:   Lactation Connection, PO Box 265, Bluff Dale, TX 76433.  Questions?  Call 800-216-8151. 

Name:  Last, First & Spouse: 

Street Address:   

City:    State:    Zip: 

Drivers License State:          Number: 

Date of Birth:    

Email address:        

Credit Card #:              Expiration Date:                CVV Code: 

telephone#           work/mobile#

Check the applicable boxes below.   Your order will be processed without tax if you are outside Texas.  Texas residents add 6.75%.   $25 shipping will be added to all orders for rentals.  This will cover Fedex ground shipping as well a return label for return shipping that will be emailed upon your request.  (Terms of rentals will begin up to 5 days after ship date to allow for rental to arrive.  Returns are considered on-time if scanned by FedEx on or before the date due.) 

NOTE:  Choose Daily Weight Scale (weights in 1/2 oz increments) or BMI Baby Scale (weighs in 5 gram/0.18 oz increments and has memory for breast milk intake purposes). 

Select Applicable Item:  one mo Daily weight scale rental  $45  one mo breast milk intake scale rental  $55    two mo scale BMI scale rental $80 

two mo scale Daily Weight scale rental  $60  add additional  $25 for 2-3 Day Premium Shipping

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 and $30-55 per month thereafter. This rate is based on the prorated amount 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 $5 cleaning fee if scale is not clean upon return.

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 address.

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