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Ameda Platinum Breast Pump Rental Agreement - Long Term

In order to rent a breast pump, print this page, complete form 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

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: Please check initial rental and quarterly renewal unless you will be returning your breast pump at the end of the initial period. Otherwise, it may be necessary to fill out a new contract upon renewal.

___six mo rental $390
___quarterly renewal $195

Choose accessory option below (required):

___I already have an Ameda personal hygiene double pumping kit.

___Double pumping collection kit $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 and $195 quarterly thereafter if pump is not returned by the end of initital contract date. 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. $35 shipping fee will be added to orders for this pump. 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:


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.