j Equipment Rental Agreement

Medela Equipment Rental Agreement

By end of your Contract's due date, you must return our Equipment to our Rental Station. Scroll down to read and acknowledge *Terms of Agreement
Indicate your rental depot here:

Diana Gifford, IBCLC - 613 Edgefield Dr, Garland, TX 75040, (469) 844-3574Sharon Mattes, IBCLC - 1526 Archery Ln, Garland, TX 75044, (972) 977-1685
IT IS THE LESSEE'S RESPONSIBILITY TO RETURN EQUIPMENT (Medela Symphony Breast Pump or BabyWeigh II Scale) TO THE RENTAL STATION BY THE 'DATE DUE FOR RETURN' LISTED ON THIS SIGNED CONTRACT.

Delivery & Pick-up Costs vary according to distance/travel time. Equipment is delivered or picked up 'free of charge' ONLY if you have a Home Visit Appointment at the time equipment is rented or due to be returned to us.

Client may request to Extend Rental Agreement to a later date with verbal consent by phone, text, or email at any time. Payment agreement for extension will be arranged and a new return date agreed upon.
Lessee Name*

First NameLast Name
Partner Name (Secondary Contact)*

First NameLast Name
Email*
example@example.com
Lessee Date of Birth*

MonthDayYear
Date
Drivers License State
Lessee Drivers License Number*
This information is required for rental. If you prefer, you may call to give the number to the rental station.
Lessee Phone #*

Area CodePhone Number
Partner Phone # (Need a Secondary Contact)*

Area CodePhone Number
Address*

House number and street name

Unit number

CityState / Province

Postal / Zip Code
Do you have a physician's prescription for your Equipment?
If NO - you'll pay the 8.25% tax on the rental - If YES - tax fee is waived if copy is received
Term of Lease (BabyWeigh II Scale)

Daily Rate - $ 5 + .40 tax1 week - $ 35 + 2.90 tax1 month - $ 85 +7.00 tax3 month - $225 + 18.55 tax
Term of Lease - Symphony Pump

Daily Rate - $ 5 + .40 tax1 week - $ 35 + 2.90 tax1 month - $ 85 + 7.00 tax3 month - $225 + 18.55 tax
Date Equipment Rented*

MonthDayYear
Date
Date Equipment Due for Return*

MonthDayYear
Date
Do you need a Symphony or Lactina Pump Accessory Kit for $50.00 + $4.13 tax? (Accessory kit has caps & membranes needed to operate the pump.

YesNo, I have one already
Do you need Medela Pump Accessories or Products? (Contact Rental Station. They will give you the price total for accessories and/or individual parts)

YesNo
Total Advance Payment Owed
EQUIPMENT RENTAL + KIT + PARTS + TAX
*Terms of Agreement for Medela BabyWeigh II Scale and/or Symphony Pump includes Cord, Cord Cover & Screw, Bottle Holder & Pump Case with Shoulder Strap or Scale Case.
- The Medela Scale/Pump, Cord, Cord Cover & Screw, Bottle Holder & Pump Case with Shoulder Strap, shall remain the property of the Medela Inc, McHenry, IL.
- Lessee may purchase a Pump Kit if desired. The kit once purchased will become the prosperty of the lessee and is not returnable.
- Lessee agrees to pay the rental fee in accordance with the fee structure of rental station.
- Lessee agrees to inform rental station of any changes in address.
- Lessee agrees NOT to move pump equipment out of state without informing Rental station
- Lessee agrees to 'allow no other person' than Lessee to use this equipment.
- Lessee agrees to return all equipment in a clean condition and in good repair.
- If the equipment is missing or not in good repair, Rental station reserves the right to charge Lessee a minimum of $40.
- The Lessee shall be charged $5. a day for every day rental pump is overdue.
- The Rental Station has the right to cancel this agreement at any time with a three day notice.
RENTAL STATION WARRANTS TO REPAIR OR REPLACE ANY EQUIPMENT WHICH IS OR BECOMES DEFECTIVE UNDER NORMAL USE. RENTAL STATION AND MEDELA, INC. WILL NOT BE LIABLE FOR INCIDENTAL, CONSEQUENTIAL OR ANY OTHER DAMAGES RESULTING FROM DEFECTIVE EQUIPMENT; THEIR LIABILITY IS LIMITED TO REPAIR OR REPLACEMENT OF EQUIPMENT; THIS WARRANTY IS GIVEN IN LIEU OF ALL OTHER WARRANTIES EXPRESSED OR IMPLIED. (Updated 04/16/2024)
Signature*

Clear
Serial Number and Due Date:

When office receives your contract you'll be notified of your Scale or Pump Serial Number & the Date to return this equipment
Rental Extension Details
How Paid - When Due
Check box on pump client is leasing

Symphony Serial #1398561Symphony Serial #1695306Symphony Serial #1785139Symphony Serial #2014312Symphony Serial #2018881Symphony Serial #2024581Baby Weigh Serial #76420Baby Weight Serial #Other
Contract paid in advance by:

CashInsuranceCheckZelleVenmoCr Card
Credit Card #: blank Exp Date: Date 3-4 Digit Sec Code: blank
Should be Empty:

Medela Equipment Rental Agreement

Serial Number and Due Date: