Service and Repair agreement

Service - Repair Agreement
Request date

MonthDayYear
Date
Service options

In store service - repairOn-site service - repair $120Equipment Pickup $60
On-site - pickup costs:

Whitin 25 KM $50Further $75
Existing client:

YesNo
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
POA - Family contact information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Product to be serviced

Battery only $75Walker - Rollator $90Hospital Bed $120Lift Chair $120Wheelchair $120Power operated vehicle $200Other $120 - Hr
Reason for Service - Repair
IName and last name* am aware that it could take 3-4 business days for a service-repair assessment to take place. I agree to let Capital Home Medical Equipment bill my credit card (as seen below) for the repair rates listed below.
Parts billed separately: Client will be contacted prior to moving forward for any charges over and above tha base cost listed above.

Client will be billed automatically for repairs and assessment when they are completed.
Credit card information*
Expiry:*
Type a question

VisaMastercard
Signature

Clear
Kanata

Hazeldean Mall17 - 300 Eagleson RoadKanata, ON K2M 1C9
Barrhaven

Medical Centre205 - 16 Green StreetNepean ON K2J 3R2
Downtown

The Doctor's Building202 - 267 O'Connor Street Ottawa, ON K2P 1V3
Should be Empty:

Kanata