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M-F 9-5 CST

Empowering the Nation to Latch On Since 1993!

$6 SHIPPING

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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 or mail the signed copy to: 877-909-7867  Lactation Connection, 15036 CR 156, Bluff Dale, TX 76433.  Questions?  Call 877-967-7867.

Name:  Last, First & Spouse: 

Street Address:   

City:    State:    Zip: 

Drivers License State:          Number: 

Social Security Number:    

Email address:        

Credit Card #:              Expiration Date: 

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 to you as well a call tag that will be issued as soon as you contact us 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.)

one mo rental  $ 50     one mo scale rental   $35     three mo rental  $ 125       five mo rental  $ 150          double pumping collection kit  $ 44.99           add additional  $15 for 2nd Day Air 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 $1.06 - $1.67 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 posession:  Ameda  Medela.  These plastic 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  Rental: 

                                            

Ameda-Egnell Lact-E 

Medela Lactina Select...only available for pick up or delivery in DFW, but the Medela kit will fit the Lact-E.     

Digital Baby Scale

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