Pump/Scale Rental Subscription Contract

Pump/Scale Rental Subscription Contract
Parent's Name*

First NameLast Name
Parent's Date of Birth*

MonthDayYear
Date
Baby's name (if applicable)

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Pump/Scale Make, Model and Serial Number (if known)
Type of equipment you would like:*

Ameda Elite PumpAmeda Platinum PumpMedela Symphony Pump (currently out of stock)whatever hospital-grade pump is availableInfant scale
What date would you prefer to pick up your pump/scale? We will contact you to confirm a pick-up time. *

MonthDayYear
Date
This agreement for the rental of this equipment/pump is made between the Rental Station and the Lessee identified above.

1) This breast pump/equipment remains the property of Luna Lactation, LLC. Lessee has no rights to such breastpump except as expressed in this agreement.

2) Lessee may purchase the accessory collection kit to use with the breastpump. The kit becomes the property of the Lessee and is nonrefundable.

3) Lessee agrees to pay the rental fees as shown above. Rental fees are due in advance. If Lessee wishes to continue renting the breastpump longer than originally agreed, they must contact Luna Lactation Rental Station office above and make arrangements for payment to extend the rental. Luna Lactation will automatically charge/invoice for the following rental period if the equipment hasn't been returned.

4) Applicable state Sales Tax will be charge on breastpump rental as well as collection kit unless a physician’s prescription for a breastpump is provided. None owed in Oregon.

5) Lessee agrees not to move the breastpump out of this State without the consent of the Luna Lactation.

6) Lessee agrees to inform Luna Lactation of any change of address or phone number.

7) Lessee agrees to return the equipment in clean condition. If the equipment is not cleaned, Lessee agrees to pay Luna Lactationa cleaning fee of $10.00 to $25.00 depending on the condition of the breastpump. Window cleaner or all purpose cleaner spray can be used to clean the equipment and case.

8) Lessee agrees to return the equipment in good repair. If the equipment is not in good repair, Lessee will be resposible for repairing or replacing the equipment.

9) Lessee shall be responsible for all reasonable legal fees and other costs involved in collection of overdue amounts and/or recovery of the equipment.

10) Lessee understands the Rental Station has the right to cancel this agreement at any time with three days notice.

11) Lessee agrees that their payment method on file will be charged for the full amount of replacement equipment if the equipment is not returned or must be repaired/replaced (equipment purchased new runs from $800-2100).

12) Lessee agrees any unpaid balance will be charged to their credit card or payment method on filewhen equipment is returned.

15) Lessee agrees to allow Luna Lactation or any agency involved in collection of overdue amounts and/or the rental equipment to obtain a credit report on Lessee.

I hereby agree to the terms and conditions of this rental agreement. I also authorize Luna Lactation to charge my credit card according to the plan selected above and the terms of this rental agreement if payment is not made by cash or check at time of rental.
Check here if you need a pump kit (tubing, bottles, flanges, etc), and we will send you a separate invoice for the kit:

Pump Kit $45

My Products*

Monthly Infant Scale Rental($30.00 for each month)

Monthly Pump Rental($50.00 for each month)

Credit Card

Signature*

Clear
Please upload an official photo ID, like a driver's license. We must be able to track our pumps if they aren't returned properly. Thank you for understanding.*

Browse Files

Cancelof
PRIVACY NOTICE: The information collected in this contract is considered nonpublic personal information and will only be used in accordance with this contract. We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations regarding your privacy and to guard all nonpublic information.
Should be Empty: