Loaner PAP Inventory Record Form

APDME PAP Loaner Management
Patient Name*
Patient MRN#*
Patient Device Serial#*
Loaner PAP Device Serial#*
Expected Return of Loaner*
Reason for Loaner PAP*
I, {patientName}, agree to assume full responsibility for the safe keeping and care of the PAP equipment while it’s in my possession. I assume responsibility for any damage to the equipment due to neglect or misuse until I have returned it. I understand that failure to return the equipment on the return date will result in a bill generated to cover the cost of the equipment.
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Signature: {patientName}
Should be Empty:

APDME PAP Loaner Management