HEALTHCARE LENDING AGREEMENT

This form is for use by healthcare professionals or professional caregivers only.

All HME recipients (clients) or their representative are required to electronically sign the lending agreement, releasing STLHELP and you from liability.

Your patient or their representative will need to complete the "release form" section of this request. Then, should STLHELP have the item, it will be ready for pick up with no further paperwork.

STLHELP is honored to serve you and those you seek to help.

Patient's Name

First NameLast Name

Patient's zip code

If we have the equipment available; where would be the preferable place to pick up:

Is the home medical equipment requested a POWER SCOOTER or a POWER WHEELCHAIR?

HOME MEDICAL EQUIPMENT REQUESTED: PLEASE DESCRIBE YOUR CLIENT'S NEED

HME, describe what you need

Please select requested Home Medical Equipment.

Note we cannot guarantee to have the item(s).

Please select requested Home Medical Equipment

Patient's Height

Patient's Weight

Client's weight

Patient's Email Address

example@example.com

Patient's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient's age:

Is patient age 65 or older?

Is the Patient a Veteran?

Ethnicity of Patient

Your patient's gender

Gender of Patient:

Patient 's Estimated Income:

Please rate your quality of life if you are the recipient, or if you are a caregiver, please rate the quality of life for the patient/recipient at this time.

1 is Worst, 5 is Best

Please rate your quality of life if you are the recipient, or if you are a caregiver, please rate the quality of life for the patient/recipient at this time.

1 is Worst, 5 is Best

How did you learn of the St. Louis Health Equipment Lending Program?

Select all that apply. Why did you contact the St. Louis Health Equipment Lending Program for health equipment

I understand that the St. Louis Health Equipment does not repair, replace or in any way assist in the operation and maintenance of the POWER SCOOTER or POWER WHEELCHAIR. The user of the power wheelchair is responsible for using it safely. According to the National Institute of Health, "Power wheelchairs enhance quality of life by enabling occupation, improving self-esteem and facilitating social interaction. Despite these benefits, there are risks associated with power mobility use; and accidents, which may occur, are a serious concern." You have read these notices and still want the power chair.

Please contribute to the St. Louis Health Equipment Lending Program. Your help allows us to assist others who are in need.

Healthcare Professional's Name (pick up person)

Name of person who will pick up equipment

Healthcare Professional's Phone

Please enter a valid phone number.Format: (000) 000-0000.

Healthcare Professional's Place of Work

Healthcare Professional's Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Healthcare Professional's Email Address

example@example.com

Equipment Lending Agreement (to be signed by potential recipients or their representative)

(please read and type signature when prompted)

This agreement is a release of the recipient’s rights to sue for injuries or death resulting from the loaned equipment. Recipient expressly assumes all risks related in any way to the use of this loaned equipment. Equipment will be loaned at no charge and should be returned by recipient clean and in good condition when no longer needed. Recipient acknowledges that the equipment is in good working condition and that he/she has examined the equipment to inspect its condition and identify any defects. Any damage or replacements are to be made at the expense of the recipient and not St. Louis HELP. Recipient also understands that St. Lous HELP, and its employees, officers, volunteers or agents (hereinafter “Released Parties”), shall not be held liable or responsible in any way for injury, death or other damages to recipient or his/her family, heirs or assigns which may occur as a result of the loaned equipment or as a result of product defect, or the negligence of any party, including the Released Parties, whether passive or active.

I have carefully read and understand the above agreement. By signing this agreement, I exempt and release St. Louis Health Equipment Lending Program, a nonprofit, from all liability and responsibility whatsoever for personal injury, property damage, or wrongful death as a result of receiving equipment, however caused, included, but not limited to product liability or negligence of the released parties, whether passive or active.

Name

First NameLast Name

Signature required

Date

MonthDayYear

STLHELP HOME MEDICAL EQUIPMENT