Rental Equipment Interest Form

Rental Equipment Interest Form
Please note that completion of this form does not guarantee the availability of desired rental equipment. Please call the store to verify the supply.

Wheelchair Rental: $45/week or $55/week with leg lifts

Knee Scooter Rental: $45/week

Commit to one month and pay $170 upfront on any rental.
Personal Information
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

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

Location

Which location would you like to rent from?*

	Desired Location
WESTFIELD: 211 Jersey St., Westfield, IN 46074 Phone: 317-896-9378
SHERIDAN: 508 E 10th St., Sheridan, IN 46069 Phone: 317-758-4171

Rental Information
What type of equipment would you like to rent?*

Knee ScooterWheelchair
Would you like a leg rest?

YesNo
A leg rest allows the user to elevate their leg and keep it in a straight position if they are unable to move it
On what date would you like to rent?*

MonthDayYear
Date
How long would you like to rent for?
I would like to rent for number of weeks/months* Week(s) Month(s)

*Rental equipment is available in week or month long durations

Knee Scooter Rental Rates
** If you would like to buyout a rental scooter or need to extend the due date you must contact the store and speak with someone to confirm details at a minimum of 24 hours before the due date.

**Late fees will be charged until the buyout price has been reached. At that point the renter will have paid in full for the cost of the merchandise and will not be charged additional late fees

Wheelchair Rental Rates
** If you would like to buyout a rental wheelchair or need to extend the due date you must contact the store and speak with someone to confirm details at a minimum of 24 hours before the due date.

**Late fees will be charged until the buyout price has been reached. At that point the renter will have paid in full for the cost of the merchandise and will not be charged additional late fees

Credit Card Authorizations
I authorize ELLA Community Pharmacy Enterprises, LLC and its subsidiaries (Westfield Pharmacy and Sheridan-Elliott Pharmacies) to charge the following credit card for rental equipment and charges in accordance to the rental agreement form up to and including per term rental rates, charges for optional services or cleaning, applicable taxes, losses or damage to the equipment, charges for late return of equipment or buyout rates of non-returned equipment, and costs incurred for payments with insufficient funds.

I understand that the card charge will be posted at time of service and a receipt of transaction will be attached with the items/services provided for the transaction. If you would like a detailed statement of items, request must be made in person or via phone. There is a $1.00 charge (plus postage if mailed) for printed detailed statements.

I understand it is my responsibility to notify the pharmacy of changes to my contact information and/or if my credit card has expired or canceled. If my credit card information changes, I agree to provide a new card, and this can be used with the same authorization as before.

I, the undersigned, do hereby agree to pay for, and guarantee the payment of, any and all such sums of money that may now or shall hereafter, by owing ELLA Community Pharmacy Enterprises, LLC for the said items furnished and supplied to said patient for which the amount, or amounts, this instrument shall constitute a continuing and unconditional guaranty.

In the event that you are liable for any amounts owed to ELLA Community Pharmacy Enterprises, LLC, we may initiate a transaction via your default payment method or other available payments to pay such amounts. If you do not have sufficient funds available to fulfill such payment, ELLA Community Pharmacy Enterprises, LLC may engage in collection efforts and/or legal actions to recover such amounts from you.

At this time, ELLA Community Pharmacy Enterprises, LLC will accept MasterCard, Visa, American Express and Discover.
Cardholder Name*

First NameLast Name
Cardholder's Phone Number
Please enter a valid phone number.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 digits of credit card number*
*Additional card information will be collected at date of rental
Signature

Clear
Date*
Type your name here (to serve as your electronic signature)*
By selecting the "submit" button below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Equipment Rental Agreement
This Equipment Rental Agreement (“Agreement”) is effective as of the date of signature (“Effective Date”) and is made between ELLA Community Pharmacy Enterprises, LLC, with business locations at 211 Jersey St., Westfield, IN, and 508 E 10th St, Sheridan, IN (“Owner”), and First Name* Last Name* (“Renter”).
Owner and Renter are hereinafter collectively referred to as “Parties”. Owner rents to Renter and Renter rents from Owner, subject to the terms and conditions of this Agreement: Medical Equipment described on receipt/invoice

1. Term. This Agreement shall commence on the Effective Date and remain in full force and effect until Equipment is returned to the Owner. Renter shall return the equipment before closing of business on agreed upon return date unless terminated earlier consistent with the terms herein. No refunds will be issued for equipment returned prior to this listed date.

2. Payment. Renter shall pay the amount agreed upon at pickup for the agreed upon rental time and authorize Owner to charge the debit card or credit card on file with Owner an amount equal to all payments and fees due under this Agreement.
Renter shall also pay other charges in accordance with this Agreement due upon return of Equipment, to the fullest extent allowed by law, including but not limited to:
a) charges for optional services or cleaning, if any;
b) applicable taxes;
c) loss of, or damage or repair to the Equipment, loss of use, diminution of the Equipment’s value caused by damage to it or repair to it, and costs to enforce such charges including administrative fees for processing the claim and legal expenses;
d) a $10 charge per day for late return of the Equipment, up to the original full retail cost of the equipment listed on the signed equipment form.
e) unless due to the fault of the Owner, all fines, penalties, court costs, and other expenses relating to the Equipment assessed against the Owner or the Equipment during the rental Term;
f) all expenses that the Owner incurs due to Renter’s failure to return the Equipment including costs in locating and recovering the Equipment;
i) all costs incurred to collect unpaid monies due; and
k) twenty-five dollars ($25.00) or the maximum amount allowed by law, whichever is greater, for making a payment with insufficient funds.

3. Location of Equipment. During the Term, Equipment shall be located at the customer’s home address -or- in his/her possession, unless expressly agreed otherwise in writing by the Owner.

4. Care of Equipment. Equipment can only be used in a careful and proper manner and shall not be used in any way that is inconsistent with Owner’s instructions or manuals. Equipment that is damaged or needs extensive cleaning due to cigarette smoke smell or other causes may be due an additional cleaning fee not to exceed one-half the cost of the equipment.

5. Repair and Alterations. Equipment shall not be serviced or repaired, and parts and accessories shall not be replaced without Owner’s prior consent.
6. Restrictions on Use. Renter shall not: a) permit the Equipment to be used by any person who is not authorized to use such Equipment; b) operate, use, maintain or store the Equipment in a manner likely to cause damage to the Equipment.

7. Loss or Damage. The Renter shall immediately alert the Owner to any damage to the Equipment. Renter shall be responsible for any loss or damage to Equipment and loss of use, diminution of the Equipment’s value caused by damage to it or repair to it, and missing equipment.

8. Condition of Equipment. Renter acknowledges that Renter has examined the Equipment and that it is in good condition except as otherwise specified. OWNER MAKES NO WARRANTY, EXPRESS OR IMPLIED, COURSE OF DEALING, COURSE OF PERFORMANCE, USAGE OF TRADE OR OTHERWISE, AND EXPRESSLY EXCLUDES AND DISCLAIMS ALL WARRANTIES AND REPRESENTATIONS OF ANY KIND, INCLUDING ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT.

9. Return of Equipment. Renter shall return Equipment on the date specified in Section 1 in the same condition as Renter received it, except for normal wear and tear. Renter shall return the Equipment to the original site of rental: either 211 Jersey St., Westfield, IN, or 508 E 10th St., Sheridan, IN. If Equipment is not returned on said date to the correct location, the Owner reserves the right to take any action necessary to regain possession of the Equipment.

10. Termination. This Agreement shall terminate on the date specified in Section 1. Owner reserves the right to terminate this Agreement earlier upon notice to Renter.

11. Indemnification and Liability. Renter shall indemnify, defend and hold harmless Owner from and against any claim, demand, cause of action, loss, or liability (including attorney’s fees and expenses of litigation) for any property damage or personal injury arising from Renter’s use of Equipment by any cause, except to the extent caused by Owner’s gross negligence or willful misconduct. The provisions of this Article shall survive the termination of this Agreement with respect to any claims or liability accruing before such termination. IN NO EVENT SHALL OWNER BE LIABLE FOR ANY INDIRECT, SPECIAL OR CONSEQUENTIAL LOSS OR DAMAGES ARISING FROM RENTER’S USE or MISUSE OF EQUIPMENT, INCLUDING BUT NOT LIMITED TO LOSS PROFITS AND LOSS REVENUE, EVEN IF INFORMED OF THE POSSIBILITY OF SUCH DAMAGES.

12. Ownership. Owner shall at all times retain ownership and title to the Equipment. Renter shall immediately notify Owner in the event Equipment is levied, has a lien attached, or is threatened with seizure. Renter shall indemnify and hold Owner harmless against all loss and damages caused by such action. Equipment shall be deemed at all times to be personal property, whether or not it may be attached to any other property. The Renter will only obtain ownership of equipment if late fees have been charged up to the full original retail cost of the equipment, or by the Renter’s choice of paying the full retail value of the equipment to obtain ownership.

13. Waiver. No failure of the Owner to exercise or enforce any of its rights under this Agreement shall act as a waiver of subsequent breaches, and the waiver of any breach shall not act as a waiver of subsequent breaches. The Owner’s acceptance of payment with knowledge of a default by the Renter shall not constitute a waiver of any breach.

14. Severability. In the event any provision of this Agreement is held by a court or other tribunal of competent jurisdiction to be unenforceable, that provision will be enforced to the maximum extent permissible under applicable law, and the other provisions of this Agreement will remain in full force and effect. The parties further agree that in the event such provision is an essential part of this Agreement, they will begin negotiations for a suitable replacement provision.

15. Entire Agreement. This Agreement represents the entire understanding relating to the subject matter hereof and prevails over any prior or contemporaneous, conflicting, or additional communications. This Agreement can only be modified by a written amendment signed by the party against whom enforcement of the such modification is sought.

16. Counterparts. This Agreement, and any amendment thereof, may be executed in two or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same document. Renter acknowledges receipt of a copy of this Agreement and acknowledges having read and understood the foregoing.

OWNER NAME (ELLA Community Pharmacy, LLC)
Renter Name: First Name* Last Name*
Date*
Renter's Signature

Clear
Date*
Type your name here (to serve as your electronic signature)*
By selecting the "submit" button below, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.
Owner's Signature

Erik Angelotti

Electronically Signed
Today's Date
Should be Empty: