Diaper Rental Order Form

Diaper Rental Order Form

Wash-at-Home diaper rentals
Delivery Information

Enter the name & contact info of the recipient of the diaper rental package
Recipient Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Delivery Address*

Street Address

Street Address Line 2

CityState

Zip Code
Estimated Due Date*

MonthDayYear
Date
Billing Information

If purchasing as a gift, enter the name & contact info of the person making the payment(s)
Same as Delivery info?*

YesNo
Billing Name

First NameLast Name
Billing Phone Number

Area CodePhone Number
Billing Email
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Customize Your Rental Package
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Laundry Bundle$29.00
Includes 1 pack of Esembly washing powder & one, 6-pack of agitator balls. (one-time fee, washing powder can be reordered as needed for $18.50 per bag.)

Diaper Rental Package$10.34
18-36 prefold cotton diapers (depending on size), 8 waterproof covers, and 45 cotton flannel wipes to rent and wash-at-home. (Billed weekly)

SizeStyle

Optional Add-On Rentals$2.00
Choose to add 8 Waterproof Covers, 36 Flannel Cotton Wipes, or both to your rental stash. Renatl add-on prices are weekly.

Combo

Snappi fasteners$10.00
3-pack, only necessary for prefold diapers (one-time purchase)

Condition

Esembly Skin Care Bundle$28.00
Cloth-friendly, effective, and all-natural skin care products from Esembly baby. Everyday balm and Rash relief cream are the perfect pair for protecting and soothing skin. (One-time add on purchase, each item can be reordered as needed.)

Pail Pouch$25.00
The Pail Pouch is waterproof and holds up to 3 days of diapers and accessories. It can be used to line your diaper pail, or on its own by hanging over a doorknob or hook. Made of recycled fabric from 100% post-consumer plastic bottles! *One-time add-on purchase

Quantity

Heavy Duty Diaper Pail$39.99
The Odor-Free Diaper Pail keeps diapers out of sight and smell. The replaceable activated charcoal filter releases the moisture and contains the smell while plastic handles ensure the lid is sealed tight. Snug-fitting, lockable, child-proof lid conceals odors and is properly ventilated to allow the contents to breathe without releasing odors. *One-time add on purchase

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Diaper Rental Order Form

Delivery Information

Billing Information