Medela Breast Pump Rental (Subscription)- FINAL

Medela Breast Pump Rental Request

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Name*

First NameLast Name
Patient's Date of Birth (required for validating payment through our secure text-to-pay feature)

MonthDayYear
Date
Phone*
Email*
example@example.com
Would you like your equipment rental delivered directly to you? ($10 delivery fee)*

YesNo, I will pickup at the nearest Good Day Pharmacy
Please note

We are able to deliver to most addresses in:
- Eaton
- Fort Collins
- Greeley
- Johnstown
- Longmont
- Loveland
- Timnath
- Windsor
Home Address (for billing or delivery purposes)*

Street Address

Street Address Line 2

City

Zip Code
Medela Symphony Plus Breast Pump

Initiation Technology™: Symphony PLUS technology used soon after birth can significantly increase breast milk production. The INITIATE program contains a mixture of stimulation phases, an expression phase, and a pause phase that mimic healthy infant feeding behaviors.

2-Phase Expression® technology: Can be used by all mothers to help build and maintain milk production. MAINTAIN program can be used to build upon initiation and maintain their milk production.

Convenient: Single or double pumping.
Two separate, independent membrane units: This allows switching between single and double pumping by simply applying or removing the second collection kit to the breast.

Let-down button: Moms can easily return to stimulation by pressing the let-down button.
Initiate and maintain milk supply: If direct breastfeeding is not possible, as well as collect breast milk at work or during other absences from the baby.

Hospital-grade (multi-user): The pump's kit is separate from the pumping mechanism and protected from overflow by a specially designed membrane.

*Please Note - The Pump Rental does not include any tubing or accessories. Unless previously purchased, our recommendation is to add the 'Double Breast Pump Kit' to your order. Follow the link after submitting your order (or use the link in your confirmation email).
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Medela Breast Pump Rental - 1 WeekThis is a one-week rental of the hospital-grade, Medela Symphony plus breast pump
($28.00 for 7 days)



Medela Breast Pump Rental - 1 MonthThis is a one-month (31 days) rental of the hospital-grade, Medela Symphony plus breast pump
($75.00 for 1 months)



Medela Breast Pump Rental - 2 WeeksThis is a two-week rental of the hospital grade, Medela Symphony breast pump
($50.00 for 2 weeks)
From Which Good Day Pharmacy Location will you be picking up?*

Eaton (180 S. Elm Avenue in Heritage Market)Fort Collins (2601 S. Lemay)Fort Collins (2001 S. Shields)Greeley (4239 Centerplace Dr. Unit 1D)Johnstown (201 Johnstown Center Dr. in Hays Market)Longmont (1749 Main St)Loveland (2033 Boise Ave.)Wellington (7702 5th St)
Enter the date you wish to receive the medical equipment *

MonthDayYear
Please allow 24 hours to process request. If you're needing equipment before next busniess day, please call your local Good Day Pharmacy.
How did you hear about us?

Your Provider/PhysicianFacebook/Social MediaGoogle/Online SearchFamily/FriendPast CustomerRadioOther
Provider Name

First NameLast Name
Billing Zip Code*
5 Digit Zip Code
If the equipment is lost or broken beyond repair, customer will pay the price of the equipment to replace, plus shipping and handling. (please initial)*
If the equipment is returned and needs to be repaired because of damage beyond use, the customer will be charged for parts and labor of repair. (please initial)*
If the equipment is returned and is visibly dirty, the customer will be charged a $25 cleaning fee at the time of return. (please initial)*
If the equipment rental is cancelled, the customer will be charged a $10 restocking fee at the time of return + 3% Refund fee (from Paypal). This is to accommodate the time and resources spent delivering equipment between locations. (please initial)*
You acknowledge that this equipment remains the property of Medela, LLC and by signing, you authorize Good Day Pharmacy to obtain your credit card information in order to receive this rental. *

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Please allow one business days to process your order.
After hitting submit and completing your payment, you'll be redirected to a form where you can easily add accessories to complement your breast pump.
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Medela Breast Pump Rental Request