Rental Agreement

Description of Items Rented:

Total Paid Including Tax:

$

Customer

First Name

Last Name

Address

City

State/Province

Zip/Postal

Phone

Email

By signing this form, I acknowledge that I have read the rental agreement and understand the terms and conditions set forth herein.
I also agree to the charges being made to my credit card and understand that if the rented item(s) is not returned on or before the agreed upon WEEKLY/MONTHLY RENTAL REOCCURRING RE-RENTAL DATE, additional charges will be incurred.
I authorize Healthcare DME to charge the credit card indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; as long as the transaction corresponds to the terms indicated in this form.

Credit/Debit Card #:

Expiration:

Credit Card Type:

CVV:

Customer Driver License #:

Customer Height (Inch):

Customer Weight (lbs):

"A COPY OF YOUR GOVERNMENT ISSUED PHOTO IDENTIFICATION CARD IS REQUIRED TO BE ON FILE WITH THIS DURABLE MEDICAL EQUIPMENT RENTAL AGREEMENT."

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The terms below govern the rental agreement.

The medical equipment is the property of Healthcare DME and is in good condition. Renter shall return equipment in the same condition as when received to Healthcare DME, at the end of the rental period for inspection, or sooner, upon the demand by Healthcare DME. Healthcare DME may repossess the medical equipment without demand at any time if the equipment is used in any way that may violate the terms of this agreement.
Healthcare DME shall not be liable and/or responsible for the loss of or damage to any property left, lost, damaged, stolen, stored or transported by Renter, its agents, servants, or employees, or any other person on or using the medical equipment, either before or after the return thereof to Healthcare DME. Renter assumes all risk of such loss or damage and waives all claims against Healthcare DME by reason thereof and Renter agrees to hold Healthcare DME harmless from and to defend and indemnify Healthcare DME against all claims based upon or arising out of such loss or damage.
Renter assumes all risk and liability for any loss, damage or injury, including death, to persons or property of Renter, Patient, or others arising out of the use or operation of the medical equipment.

Rental Equipment Repairs/Maintenance Policy:

No emergency service is available for rental equipment. No onsite service is available regardless if equipment has a defect, damaged, or is unusable. Patients or customers must bring their equipment into our patient location on 2911 Carpenter Road. Ann Arbor, MI 48108 for service, repairs, or replacements Monday - Friday between the hours of (9AM-5PM EST). There is no guarantee that the patient will receive another piece of equipment, replacement is subject to stock & product availability. Rental equipment availability is not guaranteed, equipment is subject to product stock availability.
Rental equipment must be returned to Healthcare DME at our Ann Arbor, MI location, before return the equipment must be sanitized, cleaned, and in good working condition. A patient will be charged if any damages are assessed upon return of the rental equipment.
In case of any damage, the patient is responsible and solely agrees to pay in full all Labor, Material, & Parts for Damaged, Improper Use of Equipment, Excessive Wear & Tear, Water Damage, Patient Negligence, & Natural disasters for rental equipment. Patient is responsible to notate and report damages at the time of rental equipment pickup or delivery using the "Damages Assessed Form"

Rental Equipment Delivery, Pickup, Return:

Delivery of Equipment is $75 within a 20 miles radius of our Ann Arbor location. (Additional mileage will be charged $3.00 per mile.) Hospital Bed delivery/setup/pickup cost is $295.00 for patients residing within a 20 mile radius.

Pick up of Equipment is $75 within a 20 miles radius of our Ann Arbor location. (Additional mileage will be charged $3.00 per mile.)
In-store Pick-up and Drop-Off are FREE.

Security Deposit:

Prior to taking possession of the Equipment, Renter shall deposit with Healthcare DME, in trust, a security deposit as security for the performance by Renter of the terms under this agreement and for any damages caused by Renter or Renter's agents to the Equipment during the Lease Term. Healthcare DME may use part or all of the security deposit to repair any damage to Equipment caused by Renter or Renter's agents. Renter is responsible to conduct a full inspection of the equipment they are renting upon pick up or delivery and must report any damage or defects immediately upon pick up or delivery of equipment to Healthcare DME. However, Healthcare DME is not just limited to the security deposit amount and Renter remains liable for any balance. Renter shall not apply or deduct any portion of any security deposit from the last or any month's rent. Renter shall not use or apply any such security deposit at any time in lieu of payment of rent.