Hygeia EnDeare 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   Return to Home Page

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  $50    three mo rental  $120    five mo rental  $150    Hygeia double pumping collection kit purchase  $44.99   

purchase breast pump cooler carrier bag $29.99    vehicle adapter purchase $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 $30-$50 per month thereafter.  The renewal 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 Hygeia double pump collection kit!  You must already have one or purchase one today in order for your breast pump to work!

Thank you!

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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