Medical Equipment Rental Form

Medical Equipment Rental Form

Please use this form for rentals of medical equipment. All of our rentals are done on WEEKLY basis. We will collect a valid form of ID and credit card to have on file when your item is picked up or delivered. Please call us at 609-758-8829 if you have any questions about your rental or how to fill out this form. Pharmacy staff will provide training on how to operate your medical equipment at the time of pickup/delivery.
Name of Renter *

First Name Last Name
Date Of Birth of Renter *

Month Day Year
Address of Renter *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *

Confirmation Email
Pick Up Date (If renting more than 7 days please adjust quantity of rental at checkout) *
Medical Equipment Selection (Ex: quantity of 1 = 7 day rental, quantity of 2 = 14 day rental) *
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Knee Scooter with basket (7 Day Rental) Adjustable handle height, extra padded knee platform, adjustable hand brake, easy folding mechanism, weight capacity: 350 lbs
$ 55.00 # of Weeks

Transport Wheelchair (7 Day Rental) Seat dimensions: 18.5"W x 16"D, seat belt, non-skid foot plates & heels, easy adjust foot riggings, foldable, locking rear wheels, weight capacity: 300 lb, weight: 22.5 lb
$ 35.00 # of Weeks

Standard Wheelchair (7 Day Rental) Weight capacity: 300 lbs, seat dimension: 18.25"W x 16"D, non-skid foot plates & heels, easy adjust foot riggings, foldable, locking rear wheels
$ 45.00 # of Weeks

Rollator/Walker (7 Day Rental) Weight Capacity: 300 lbs, under seat pouch, padded seat, hand brakes, height adjustment knobs
$ 30.00 # of Weeks

Total

$ 0.00
By signing, I agree to indemnify and hold harmless Plumsted Pharmacy from and against any and all liability, loss, damage, expense (including legal expense), cause of action, suits, claims or judgments arising from injury or death of persons or damage to property, of any nature whatsoever, resulting from the actual or alleged presence, use, or operation of the equipment, provided such injury, death or property damage is not attributable to the negligence of Plumsted Pharmacy.

Plumsted Pharmacy owns the equipment that is being rented and I agree to not give or transfer possession of the equipment to anyone else. The equipment must be returned to where it was received. If the equipment is lost or stolen, I authorize DME to charge $450 for the replacement cost of a knee scooter and $375.00 for a wheelchair, $250 for transport chair, and $200 for a rollator walker. I understand that the weight capacity of the equipment is 300 lbs and I or the person using the medical equipment am/are within that limit. I will be instructed on the use of the equipment and operation safety when I recieve the medical equipment . I understand the Plumsted Pharmacy staff are available Monday to Friday 8:30am to 8:30pm, Saturday 9am to 6pm, and Sunday 9am to 3pm should I have any questions. I authorize Plumsted Pharmacy to debit my credit card in the amount shown below and in this form. This agreement contains the entire understanding of the parties.
I have read and understood the rental agreement terms. *

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Payment Methods

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First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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