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Breast Pump & 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 76433Questions?  Call 800-216-8151.  Click here if you are inside Texas.

Name:  Last, First & Spouse: 

Street Address:   

City:    State:    Zip: 

Drivers License State:          Number: 

Social Security Number:    

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%.   $20 shipping will be added to all orders for rentals.  This will cover UPS ground shipping as well a call tag that will be issued for return shipping.  (Terms of rentals will begin 5 days after ship date to allow for rental to arrive.  Returns are considered on-time if scanned by UPS on or before the date due.)

Select Applicable Items:    one mo rental  $60    one mo scale rental   $30    three mo rental  $135    five mo rental  $175    double pumping collection kit  $44.99    cooler/carrier bag for Elite or Lactina $29.99    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 $1.16 - $2 per day 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.  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  White RiverThese plastic hygiene kits are shown attached to the rental pumps below.  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-Egnell Lact-E   Ameda Elite   

Medela Lactina White River Concepts  First Available

 Check here for baby scale rental: Tanita Scale   

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