Hospital Bed Intake Form

*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

Is this a Rental Request or a Purchase Request?*

What Location is Closest to you?*

Request date*

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Aprox Height*

Aprox Weight*

Comes standard with half rails

HalfFull

Pressure relief foam mattress- (Comes standard with all Hospital Bed Rentals)Air Mattress no Pump (Early stage of skin breakdown)Alternating Air Mattress Pressure with Pump (More compler and-or multiple areas of skin breakdowns)True Airloss Mattres with Blower

IndependentCaregiver assist with repositioning

Average (8 - 12 hours)Moderate (12 - 18 hours)Significant (18 - 24 hours)

Moisture:

Additional accessories?

Fall MatFall Prevention Alarm

BedChairMagnetic Pull CardCardless

Other Notes:

Credit Card (LAST 4 Digits)

Exp

Terms and Conditions:

Rental is only secured once payment has been received.

Complete the purchase through: Online Store OR Authorize payment once we contact you for the full Credit Card number. We will contact you within 24 hours.

A delivery/pickup and setup fee of $175 plus HST will apply to all Hospital Bed rentals.
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.

Signature*

OFFICE USE ONLY

Type: MC VISA

FULL Credit Card Number : _____________________________________

EXP: ____/____

Hospital Bed Rental Intake Form

Electric Hospital Bed

Bed Rails

Mattress

Bed Mobility

Time on Bed

Kanata

Barrhaven

Downtown