Breast Pump 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%.   $25 shipping fee will be added to orders for rentals.  This will cover FedEx ground shipping as a label that will be emailed for return shipping upon your request.  (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.) 

Specify Length of Rental: one mo pump rental  $60   three mo rental  $135    five mo rental  $200    double pumping collection kit  $44.99    cooler/carrier bag for EnDeare, Elite or Lactina $29.99    vehicle adapter for EnDeare, Elite or Lactina $24.99    I am having my doctor fax an RX for the breast pump or scale to 877-909-7867 to avoid 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 $40-$60 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 $5 cleaning fee if my pump is not cleaned before returning.

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  Hygeia.  These plastic personal kits are shown attached to the rental pumps.  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-Elite  Ameda Egnell Lact-E   

Medela Lactina Hygeia EnDeare with Custom Audio Recording Experience  First Available

  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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