Equipment Pickup Request Form

LB Medical Equipment Retrieval

Select the facility, enter client and equipment details, and provide the pickup condition and required signatures.
Facility Name
Date and Time of Retrieval Request

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Room Number
Authorizing person
Staff member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Name
Client Phone Number
Format: (000) 000-0000.
Point of Contact
Pickup Address

Street Address

Street Address Line 2
State / ProvincePostal / Zip CodeCity
Equipment Location
Equipment Type
Other Equipment Type
Enter the last four digits of your phone number

Condition at Drop Off
Condition at Pickup
Issue Details
Photos at pickup

JPG, JPEG, PNG, or GIF
Cancelof
Photos at drop off

JPG, JPEG, PNG, or GIF
Cancelof
Person Completing Retrieval
Starting Mileage
Ending Mileage
Total Mileage
Signature of person receiving equipment.
I confirm I am receiving the listed equipment from LB Medical Equipment Retrieval and acknowledge the condition of the items at the time of receipt.

Signature of requesting client or staff.

I am requesting LB Medical equipment retrieval to pick up the listed items from a public area or staff held location. LB Medical equipment retrieval will not enter private property.
Should be Empty:

LB Medical Equipment Retrieval