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Ameda Platinum Breast Pump Rental Agreement

Note: We no longer rent breast pump nationwide. For local pick up in the Granbury Stephenville area in Texas, please call 254-728-3627. Thank you!

Complete Personal Information


Note: Address must have the same zip code as the billing address of the credit card.

Street Address :

City: State: Zip:

Drivers License State: Number:


Email Address:

Primary Credit Card #:

Exp. Date:________ CVV Code:________

Secondary* Credit Card #:

Exp. Date:________ CVV Code:________
*The Platinum rental requires two forms of payment on file.

primary telephone#

secondary phone# (work/mobile/spouse)

Specify Length of Rental:

___one mo pump rental $85

___three mo rental $225

___five mo rental $325

Choose accessory option below (required):

___I already have an Ameda personal hygiene double pumping kit.

___Double pumping collection kit $49.99

___Cooler carrier bag with blue ice $49.99

___Spare parts kit (2 tubing, 4 valves and 2 diaphragms) $29.99

___M/L CustomFit Breast Flange Pair (28.5/30.5 mm) $14.99

XL/XXL CustomFit Breast Flange Pair (32.5/36.0 mm) $14.99

Choose Sales Tax Option Below:

___My billing/shipping address is outside Texas - Sales Tax is not applicable.

___I live in TX, but I am having my doctor fax an RX for the breast pump to 877-909-7867 to avoid the sales tax.

___I am inside TX and do not want to send an RX - I understand 6.75% sales tax will be added.

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 $65-$85 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. This will cover UPS ground shipping and a label for return shipping upon your request as well as shipping insurance. Terms of rentals will begin 1-5 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.

Signature of lessee/cardholder: