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 Name
Last Name
Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Delivery Address
*
Street Address
Street Address Line 2
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Estimated Due Date
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Billing Information
If purchasing as a gift, enter the name & contact info of the person making the payment(s)
Same as Delivery info?
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Billing Name
First Name
Last Name
Billing Phone Number
-
Area Code
Phone Number
Billing Email
example@example.com
Billing Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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)
Size
Newborn (6-11 lbs.)
Infant (7-15 lbs.)
Medium (11-22 lbs.)
Regular (15-30 lbs.)
Toddler (30-45 lbs.)
Style
Prefold
Fitted
All-in-One
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
Covers
Wipes
Covers & Wipes
Snappi fasteners
$
10.00
3-pack, only necessary for prefold diapers (one-time purchase)
Condition
New
Pre-loved
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
0
1
2
3
4
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
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
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