Equipment return

Is this a...*

Lease returnRental returnExchange

Client / Primary user's name*

First NameMiddle NameLast Name

Date of notification*

Date

Client or responsible party email*

name@example.com

Phone number to confirm return*

Please enter a valid phone number.

Name of person returning equipment:*

First NameLast Name

Address of person returning equipment:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Equipment returned (Standard package)*

OxyGo NEXTO2 Concepts Oxlife Independence5-liter home stationary

Serial number*

Equipment Serial number

Returning equipment via: (Charges apply)*

Request a return shipping labelTaking to common carrierRequest courier (local area only)

Extra batteries returned*

Home stationary 5 liter concentrators do not have batteries(put 0) Portable oxygen concentrators standard package on OxyGo Next is one 16 cell (only put extra ones beside the one included on standard package) if no extra batteries, put 0

Special instructions for pickup ( approximate time of pickup etc.)*

If there isn't any special instructions put N/A

Schedule date & time for pickup return (approximate)*

Accessories returned in original condition*

YesNoMissingDamaged

Accessories note*

If accessories returned in original condition, type N/A. Theses will be inspected and processed.

Return Address:

Oxygen Parts Inc
6507 Jester Blvd
Suite 510-M
Austin, TX 78750

All equipment will be inspected. Rental period ends upon return of equipment. (Any missing or damaged equipment or accessories will be paid by renter/lessor.)

I agree that any damage or missing accessories (other than normal wear) of rental or leased equipment charges will apply. (equipment check in may take up to a week) Purchased equipment will be sent to factory for estimate*

Agreed to terms and conditions

Client signature*