Ameda Platinum Breast Pump Rental Agreement

If you wish to view our other breast pump rentals, click here.  Simply fill in the information on this form, print it out, and fax the signed copy to 877-909-7867 or mail 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:       DOB: 

Email Address:    

Primary Credit Card #:  Exp. Date:  CVV Code:  

Secondary* Credit Card #:  Exp. 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%.   $35 shipping fee will be added to orders for this pump.  This will cover FedEx ground shipping and a label for return shipping upon your request as well as shipping insurance.  Terms of rentals will begin 1 day after ship date to allow for rental to arrive.  Returns are considered on-time if scanned by FedEx on or before the date due.  *The Platinum rental requires two forms of payment on file.

Specify Length of Rental: one mo pump rental  $80   three mo rental  $195   five mo rental  $300  double pumping collection kit  $44.99   cooler carrier bag with blue ice $34.99        I am having my doctor fax an RX for the breast pump to 877-909-7867 to avoid the 6.75% sales tax required in Texas.  All other are not charged tax.

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 $60-$80 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 an Ameda double pump collection kit!  These hygienic personal kits are shown attached to the rental pumps.  You must already own a double pumping collection kit or purchase one today in order for your breast pump to work.  The Platinum Pump only works with the Ameda brand kit. 

  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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