Common Contracts
4 similar Rental Agreement contracts
PATIENT INTAKE & RENTAL AGREEMENT - COMPLETE ALL 8 PAGESRental Agreement • January 3rd, 2023 • Wyoming
Name on Card: CPAP CONNECTION REQUIRED? PLEASE CHECK BOX IF NEEDED. Billing Address: City/State/Zip: Phone Number: Shipping Charge: (Staff Use Only) Credit Card: (select one) Visa / Master Card / American Express / Discover Return Charge: (Staff Use Only) Card No: Accident Waiver: $98 or £79 per week Expiration Date: RENT RATE GIVEN (Staff Use Only) CVC Code: (the last 3 digits on the signature strip or 4 on front of an Amex) If equipment not returned, deposit amount is charged.
PATIENT INTAKE & RENTAL AGREEMENT - COMPLETE ALL 8 PAGESRental Agreement • January 5th, 2021 • Wyoming
Name on Card: Pediatric Pulse Oximeter (Infants only)(select if needed) Billing Address: Pediatric Flow Reducer (Infants only)(select if needed) City/State/Zip: CPAP4ft. Tubing (select if needed) Phone Number: Shipping Charge: (Staff Use Only) Credit Card: (select one) Visa / Master Card / American Express / Discover Return Charge: (Staff Use Only) Card No: Accident Waiver: $98 or £79 per week Expiration Date: RENT RATE GIVEN (Staff Use Only) CVC Code: (the last 3 digits on the signature strip or 4 on front of an Amex) If equipment not returned, deposit amount is charged.
PATIENT INTAKE & RENTAL AGREEMENT - COMPLETE ALL 8 PAGESRental Agreement • January 3rd, 2020 • Wyoming
Name on Card: Please ask about special accessories for Pediatric rentals or CPAPs. Billing Address: The below section is Staff Use Only Phone Number: Shipping Charge: Credit Card: (select one) Visa / Master Card / American Express / Discover Return Charge: Card No: Accident Waiver: $98 or £79 per week Expiration Date: RENT RATE GIVEN CVC Code: (the last 3 digits on the signature strip or 4 on front of an Amex) If equipment not returned, deposit amount is charged.
PATIENT INTAKE & RENTAL AGREEMENT - COMPLETE ALL 8 PAGESRental Agreement • December 20th, 2018 • Wyoming
