Breast Pump 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. 

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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 that will be emailed upon your request for return shipping.  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.

Select Applicable Items:    one mo rental  $60    three mo rental  $135    five mo rental  $200    double pumping collection kit  $44.99    purchase cooler/carrier bag for Elite or Lactina $29.99    vehicle adapter for EnDeare, Elite or Lactina $19.99     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 $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.

 Signature of lessee/cardholder:  

Please check this box if you already have a double pump collection kit!  Specify Brand of kit in your possession :  Ameda  Medela   These plastic personal hygiene kits are shown attached to the rental pumps.  You must already have one or purchase one today in order for your breast pump to work!  Thank you!

Specify Type for Breast Pump  Rental:      Ameda Elite  Ameda Egnell Lact-E

Medela Lactina First Available

Click here if you want to rent the Ameda Platinum breast pump.  Click here for Hygeia EnDeare breast pump rental.

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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