Breast Pump & Baby Scale Rentals...anywhere in Texas!  If you are in another state, 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: 

Social Security Number:    

Email address:        

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%.   $20 deliver will be added to orders for rentals that total under $100.  This will cover FedEx shipping as well a call tag that will be issued for return shipping. Shipping and pick up is FREE for order inside Texas that total over $100.  (Terms of rentals will begin 1 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.) 

Specify Length of Rental: 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    I am having my doctor fax a prescription for the breast pump or scale to 877-909-7867 so I won't have to pay the 6.75% sales tax required in Texas.

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 River.  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 Breast Pump  Rental:      Ameda-Egnell Lact-E   Ameda Elite   

Medela Lactina White River Concepts  First Available

 Check here for baby scale rental: Tanita Scale   

*Texas orders must be placed before 3 pm Monday - Friday  to receive next day delivery.

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