Equipment return

Equipment return
Is this a...
Client / Primary user's name

First NameMiddle NameLast Name
Date of notification

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client or responsible party email
name@example.com
Phone number to confirm return
Please enter a valid phone number.Format: (000) 000-0000.
Name of person returning equipment:

First NameLast Name
Address of person returning equipment:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Equipment returned (Standard package)
Serial number
Equipment Serial number
Returning equipment via: (Charges apply)
Extra batteries returned
Home stationary 5 liter concentrators do not have batteries(put 0) Portable oxygen concentrators standard package on OxyGo Next is one 16 cell (only put extra ones beside the one included on standard package) if no extra batteries, put 0
Special instructions for pickup ( approximate time of pickup etc.)
If there isn't any special instructions put N/A
Schedule date & time for pickup return (approximate)
Accessories returned in original condition
Accessories note
If accessories returned in original condition, type N/A. Theses will be inspected and processed.
Return Address:

Oxygen Parts Inc
6507 Jester Blvd
Suite 510-M
Austin, TX 78750

All equipment will be inspected. Rental period ends upon return of equipment. (Any missing or damaged equipment or accessories will be paid by renter/lessor.)
I agree that any damage or missing accessories (other than normal wear) of rental or leased equipment charges will apply. (equipment check in may take up to a week) Purchased equipment will be sent to factory for estimate
Client signature
Should be Empty: