Medical Equipment Rental
Contract and ID upload
Renters Name:
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First Name
Last Name
Email:
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Phone Number
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Please enter a valid phone number.
Patients Name
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First Name
Last Name
Patient Height:
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Patient Weight:
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Terms and Conditions
If the rental exceeds the select rental period, it will automatically convert to an ongoing 28 day rental.
I understand that if I fail to return the equipment or fail to pay the rental amount due, I will be charged the full amount of the deposit as indicated in the initial Rental Contract Details Page.
All rental fees are based on a full rental cycle. Rentals will not be prorated for any shorter or longer term, regardless of the actual rental period. Additional insurance certificates may be required for any changes to the term of contract.
I agree to be fully responsible for the equipment while it is in my possession and I will reimburse Atlantic Healthcare Products for the repair or replacement if so needed due to damage or loss. I understand that the rented equipment remains the property of Atlantic Healthcare Products and that I may not move to another residence, state or country without notifying Atlantic Healthcare Products. Non-transportable equipment may not be moved from the location to which it was delivered (as defined in the Rental Contract Detail Page.).
I acknowledge that the user of the rented equipment is within the weight requirements of the rented equipment.
I acknowledge that I have received written and verbal instructions on the safe use of the rented equipment and agree to hold Atlantic Healthcare Products and its affiliates harmless from any liability due to bodily injury or physical damage arising from the use of the rented equipment. I agree to provide these instructions to the end used of the the rented equipment.
Cleaning and/or damage fees will apply to any rented item not returned in the same condition as when it was dispensed.
If there is a legal dispute the court and venue will be limited to Palm Beach County, Florida.
All rentals require a credit card for deposit. The credit card will not be charged, however it is required to remain on file for the duration of the rental term. Deposits are equal to the retail price of the product.
All rentals require an ID to be on file.
How will security deposit information be provided?
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Credit Card will be presented at store pickup.
Credit Card will be uploaded to this form.
Please contact me at the phone number above to obtain the required information.
Credit Card & Driver's' License (front & back) required for Rental Delivery:
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