HEALTHCARE LENDING AGREEMENT

STLHELP HOME MEDICAL EQUIPMENT

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*
Patient's zip code
If we have the equipment available; where would be the preferable place to pick up: *
If we have the equipment available; where would be the preferable place to pick up:*

High Ridge (St. Martin United Church of Christ): Tues and Th: 10 am to 2 pmJefferson County HELP Warehouse (Crystal City): Wed and Sat: 9 am to 1:30 pmLemay (Aging Head Senior Center): Tues: 9 am to 3 pmMehlville (Abiding Savior Lutheran Church): Tues and Th: 10 am to noonSt. Charles (The Care Service): Fri: 9 am to 3 pmSt. Louis City Soulard (Love in Action Heath and Wellness): Mon: 10 am to noon. Call first. 314-809-7776Saint Louis HELP Warehouse (Olivette): Wed and Sat: 9 am to 1:30 pmSt. Louis North City (St. Stanislaus Polish Heritage Church): Fri: 10 am to noon. Call first. 314-809-7776
Is the home medical equipment requested a POWER SCOOTER or a POWER WHEELCHAIR?*

YesNo
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*

BedBed AlarmBed RailBedside CommodeBedside TableBicycle PeddlerCanesCrutchesElevated Toilet SeatGait TrainerGeriatric ChairHoyer Lift/slingIce Therapy MachineIncontinence ProductsKnee ScooterLift ChairPediatric EquipmentRaised Toilet SeatReacherRoho Cushion/Bed TopperRollatorShoe HornShower BenchShower ChairShower Seat/StoolSit to StandSlide BoardTrapezeTub Transfer BenchWalkerWheelchair, ManualWheelchair, TransferWound Care SuppliesOther
Patient's Height*
Patient's Height
Patient's Weight*
Patient's Weight
Client's weight*
Patient's Email Address
example@example.com
Patient's Phone Number
Please enter a valid phone number.
Patient's age:*

0 - 1819 - 3435 - 5960 and overI decline to say
Is patient age 65 or older?

YesNo
Is the Patient a Veteran?*

YesNoI decline
Ethnicity of Patient*

African AmericanCaucasianLatino, HispanicAsian/Pacific IslanderI decline to say
Your patient's gender*
Gender of Patient:*
Patient 's Estimated Income:*

Less than $10,000$10,001-$20,000$20,001-$40,000$40,000-$60,000Greater than $60,000I decline to say
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

2

3

4

5

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

2

3

4

5

1 is Worst, 5 is Best
How did you learn of the St. Louis Health Equipment Lending Program?*

FriendCaregiverHealthcare professionalFacebook/social mediawww.stlhelp.orgOther
Select all that apply. Why did you contact the St. Louis Health Equipment Lending Program for health equipment*

High co-paysWait time too longYou are healthcare professional needing to help a clientNo insuranceMedicare not approvedMedicaid not approvedOther
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.*

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

Yes, I can donate.No, I am unable to give at this time.
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.
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*

Clear
Date*

MonthDayYear
Should be Empty:

STLHELP HOME MEDICAL EQUIPMENT