PATIENT INTAKE & RENTAL AGREEMENT - COMPLETE ALL 8 PAGESPatient Intake & Rental 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.
