EQUIPMENT RENTAL ORDER
HOPKIN MANUAL SINGLE-CRANK HOSPITAL BED (M11) Deposit: RM 600, Rental: RM 150/Month/Perbulanan , Delivery/ penghantaran: RM 100 (Delivery Usually On Next Day Payment)
Customer Name / Nama Pelangan:
*
First Name
Middle Name
Last Name
I/C
*
Take Photo Of Your I/C / Sila Ambil Gambar Kad Pengenalan Anda:
*
Phone Number / Nombor Telefon:
*
-
Area Code
Phone Number
Delivery/Pickup Address ( Alamat Penghantaran ):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Date For Delivery / Tarikh Penghantaran:
*
-
Day
-
Month
Year
Date
Preferred Time for Delivery / Masa Penghantaran:
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
PM
AM/PM Option
COMPULSORY
DISINFECTION SERVICE (RM 10)
ADD ON / PENAMBAHAN:
*
PU MATTRESS-RM 298.00
RIPPLE MATTRESS (BUBBLE TYPE)-RM 168.00
PRESSURE MATTRESS (TUBE TYPE)-RM 499.00
NONE
Required Additional Charge / CAJ KEPERLUAN PENAMBAHAN:
*
First Floor installation Fee (RM50)
Second Floor installation Fee (RM80)
Third Floor installation Fee (RM110)
Fourth Floor installation Fee (RM140)
Fifth Floor installation Fee (RM170)
NONE
Total Amount Payable / BAKI PEMBAYARAN:
CONTACT US FOR ASSISTANCE:
+60 18-380 8005 / 03 - 58853936
ONLINE PAYMENT TRANSFER
CIMB BANK - JITRON HEALTHCARE SDN BHD: 8600-66-3982
Proof of Payment / Bukti Pembayaran:
*
Browse Files
Screenshot your payment slip and attach here:
Cancel
of
TERM & CONDITION:
Signature (T/tangan)
*
*Sign if you are agree with the term & conditions
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RENT NOW! / SEWA SEKARANG!
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