Rental Agreement

Rental Request & Agreement
What location is this being requested from?
Date being requested*?*

MonthDayYear
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

Postal / Zip Code
Patient Height
Required for Hospital Beds, Lift Chairs and Slings
Patient Weight
Required for Hospital Beds, Lift Chairs and Slings
Is there an Occupational Therapist or Physiotherapist for your care?
Therapist information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What items are being requested? Please choose as many as apply.

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.

$75.00CAD Quantity

Knee Scooter4 -week rental of a knee scooter

$80.00CAD

Mobility Solutions

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

$75.00CAD Quantity

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

$75.00CAD Quantity

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

$100.00CAD Quantity

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 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
Wheelchair Build Service Charge		$75.00CAD

Cold Therapy

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 System2 - week rental of Game - Ready System.

$600.00CAD Quantity

Bathroom Solutions

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 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 & 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

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

$250.00CAD

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

Total

$0.00CAD

Type a question*

VisaMastercard
Credit Card Number*
Exp Date*
*No charges will be done at this time. Credit Card Information is obtained to secure rental equipment for requested date. CHME will contact you with a confirmation of all information provided and request any additional information if needed.

Client will be billed automatically for the next rental period on late returns.
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.**
Signature

Clear
Kanata

Hazeldean Mall 17 - 300 Eagleson Road Kanata, ON K2M 1C9
Barrhaven

Medical Centre 205 - 16 Green Street Nepean ON K2J 3R2
Downtown

The Doctor's Building 120 - 267 O'Connor Street Ottawa, ON K2P 1V3
Gloucester

1756 Montreal Road, Ottawa ,ON , K1J 6N3
Should be Empty:

Rental Request & Agreement

Therapist information

Kanata

Barrhaven

Downtown

Gloucester