Rental Agreement

*IMPORTANT*
Hospital Beds, Lift Chairs & Patient Lift inquiries require a minimum of 7 business days notice ton ensure fulfillment. If urgent, please call 613-254-7550.

All other inquiries are generally available within 48 hours or less.

What location is this being requested from?

Date being requested*?*

For requests less than 24 business hours, we will do our best to accommodate. We will reach out to confirm all details necessary prior to delivery and charge.

What is being requested? Please choose as many as apply.*

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

Patient Height

Required for Hospital Beds, Walkers, Wheelchairs, Lift Chairs and Slings

Patient Weight

Required for Hospital Beds, Walkers, Wheelchairs, Lift Chairs and Slings

Is there an Occupational Therapist or Physiotherapist for your care?

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Is there a prescription or document with specifications being requested?

Please upload your document and/or prescription.

In order to reserve the correct equipment for you, we highly recommend to upload the prescription if there is one.

My Products

Walking Aids

2-Wheeled Walker4 - week rental of a 2-wheeled aluminum walker

$45.00CAD Quantity

Rollator 4 - week rental of a 4-wheeled walker with seat. Regular size, up to 300lbs

$75.00CAD Quantity

Knee Scooter4 -week rental of a knee scooter

$80.00CAD

Mobility Solutions

Transport Chair (Small Wheels) Product Image

Transport Chair (Small Wheels)4 - week rental of a push-only wheelchair.

$75.00CAD Quantity

Wheelchair CAT 1 (Big Wheels) Product Image

Wheelchair CAT 1 (Big Wheels)4 - week Rental of Self-Propelling Wheelchair.

$75.00CAD

	Quantity	Price
Wheelchair With Foot Rest		$75.00CAD
With elevating leg rest (LEFT)		$110.00CAD
With elevating leg rest (RIGHT)		$110.00CAD

Bariatric Wheelchair CAT 1 (300lbs+) Product Image

Bariatric Wheelchair CAT 1 (300lbs+)4 - week Rental of Self-Propelling Wheelchair.

$100.00CAD

	Quantity	Price
Wheelchair with Foot Rest		$100.00CAD
With elevating Leg Rest (LEFT)		$40.00CAD
With Elevating Leg Rest (RIGHT)		$40.00CAD

Electric Mobility Scooters Product Image

Electric Mobility Scooters4 - week rental of an Electric Mobility Scooter

$350.00CAD Quantity

Electric Power Chair4 - week rental of Power Chair

$350.00CAD Quantity

Wheelchair CAT 2 or 3 or 5 Product Image

Wheelchair CAT 2 or 3 or 54 - week Rental of Category 2 or 3 wheelchairs.

$250.00CAD

	Quantity	Price
Cat 2 Wheelchair		$250.00CAD
Cat 3 Wheelchair		$250.00CAD
Cat 5 Wheelchair		$250.00CAD

Cold Therapy

Cryo Cuff Cooler Only (DonJoy IceMan) Product Image

Cryo Cuff Cooler Only (DonJoy IceMan)4 - week rental of an DonJoy Cryo Cuff Cooler. Reusable Pad sold Separately.

$80.00CAD

	Quantity	Price
Rental: Cooler Only		$80.00CAD
One Time Purchase: Universal Pad (HST Included)		$164.64CAD

Game-Ready Cold Therapy & Compression System Product Image

Game-Ready Cold Therapy & Compression System2 - week rental of Game - Ready System. Pads to be chosen separately at purchase

$600.00CAD Quantity

Bathroom Solutions

Basic Commode - Without Bucket Product Image

Basic Commode - Without Bucket4 - week rental of a regular commode

$50.00CAD

	Quantity	Price
Commode Without Bucket		$50.00CAD
One-Time Purchase: Pail, Lid & Splash Guard		$15.00CAD

Bath Transfer Bench4 - week rental of a Bath Transfer Bench

$50.00CAD Quantity

Reclining Shower Chair with Commode Product Image

Reclining Shower Chair with Commode4 - week rental of a Reclining Commode

$250.00CAD Quantity

Wheeled Shower Commode4 - week rental of a Wheeled Commode

$150.00CAD Quantity

Bedroom Solutions

Hospital Bed & Accessories Product Image

Hospital Bed & Accessories4 - week rental of a Hospital bed with Foam Mattress

$250.00CAD

	Quantity	Price
Hospital Bed Rental		$250.00CAD
Delivery/ Pick Up & Set - Up (One Time Fee. HST Included)		$196.00CAD
Overbed Table Rental (5.00 off)		$35.00CAD
Fall mat Rental (10% off)		$67.50CAD

Lift Chair4 - week rental of a Lift-Chair.

$250.00CAD

	Quantity	Price
Lift Chair		$250.00CAD
Delivery/ Pick Up & Set Up (One-Time Fee. $175+ HST Included)		$196.00CAD

Bed Side Table4-Week Rental

$45.00CAD Quantity

Transfer Aids

Superpole4- Week rental Superpole

$100.00CAD

	Quantity	Price
Superpole		$100.00CAD
Delivery and Set Up (HST Included)		$134.40CAD

Patient Floor Lift4- Week rental Patient Lift. Type of sling to be determined at checkout.

$250.00CAD

	Quantity	Price
Without Sling		$250.00CAD
With Sling		$50.00CAD
Delivery (HST Included)		$134.40CAD

Total

$0.00CAD

VisaMastercard

Credit Card Number (last 4 digits ONLY). We will contact you for the full Credit Card Information. *

Only the last 4 digits. We will contact you for the full Credit Card Information.

Exp Date*

Rental is only secured once payment has been received.

Complete the purchase through:
Online Store
OR
We will contact you within 24 business hours for the full Credit Card Information.

____________________________________________________________________

For In-Store Pick Up: Capital Home Medical cannot guarantee rental will be available without a commitment to rental and cannot hold items for more than 24 hours without payment. In the unlikely event the required dates change, Capital Home Medical Equipment will honour payment for the new required dates.

IMPORTANT:

Client will be billed automatically for the next rental period on late returns.
Clients assume responsibility to schedule a pick up day for their rental medical equipment or return the equipment by the due date.
Rental starts on day of pick up / Delivery.
Rentals are not pro-rated and only available as 4-week rental.
Smoking Clause: All rentals are subject to full charge of their MSRP price in the event there is smoke damage to our equipment. Smoke damage will deem the products unrentable and unusable.**
All sales are final.

By signing this authorization form, I acknowledge and accept full responsibility for any equipment loaned to me by Capital Home Medical Equipment. I agree to return the equipment in the same condition in which it was provided, excluding normal wear and tear. I understand that I will be charged for any loss, damage, or failure to return the equipment, and I authorize Capital Home Medical Equipment to charge my credit card on file for the full cost of repair or replacement as necessary.

OFFICE USE ONLY

Type: MC VISA

FULL Credit Card Number : _____________________________________

EXP: ____/____

Rental Request & Agreement

Therapist information