***Please read through Terms and Conditions, Then Sign below***

This will not go into effect until product is Delivered.

 

I certify that the above equipment and information has been provided to me and I have been instructed on the effective and safe use of the above referenced equipment/item. I have been provided with written and verbal instruction on the safe use of the above equipment. I certify that I received the equipment is in perfect and usable condition. I the undersigning hereto, release CFS Medical Supplies and Equipment, Inc from any and all injuries arising from the equipment received, private pay or insurance. In the event my insurance does not pay for the listed equipment, I will be fully responsible to pay CFS Medical Supplies and Equipment, Inc for the equipment. * If the equipment is delivered to a listed location and moved to another location and pickup is needed a $7.00 per mile fee will be charged. If delivery/pickup is requested and confirmed for listed location and no adult is available a $40.00 fee will be charged if CFS must come a second time. 

Please note this is a rental only, not rent to own, no prorating. RENTERS AGREEMENT

Rental requirement renter must be a Major Credit Card Holder, and sign this Medical Equipment Rental Agreement. CFS Medical Supplies and Equipment, Inc. rents to Renter signing or representative signing this agreement and medical equipment stated on the line items subject to all the terms set forth in this Rental Agreement and Renter agrees: 

1. The medical equipment is the property of CFS Medical Supplies and Equipment, Inc and is in good and usable condition. Renter shall return equipment the same condition as when received to CFS Medical Supplies and Equipment, Inc., as the end of the rental period for inspection or sooner, upon the demand by CFS Medical Supplies and Equipment, Inc., CFS Medical and Equipment, Inc may repossess the medical equipment without demand at any time if it is used in violation of the terms of this agreement,

2. CFS Medical Supplies and Equipment, Inc., shall not be liable or responsible for the loss of a 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 CFS Medical Supplies and Equipment, Inc.  Renter assumes all risk or such loss or damage and waives all claims against CFS Medical Supplies and Equipment, Inc. by reason thereof and Renter agrees  to hold CFS Medical Supplies and Equipment, Inc. harmless from and to defend and indemnify CFS Medical Supplies and Equipment, Inc. against all claims based upon or arising out of such loss or damage.

3. Renter assumes all risk and liability for any loss, damage or injury, including death, to persons or property of Renter or others arising out of the use or operation of the medical equipment. 

4. The additional conditions outlined above have been reviewed and accepted as part of this agreement.

5. Renter is responsible for the medical equipment and will reimburse CFS Medical Supplies and Equipment, Inc., Legal Owner of Equipment, for the full cost of replacement upon demand for any damage, loss, theft, or destruction of the medical equipment. The Renter understands and authorize that CFS Medical Supplies and Equipment, Inc. will charge the credit card use for any repair costs or the replacement costs of the medical equipment deemed necessary. 

6. The following restrictions are cumulative and each shall apply to every use, operation of the medical equipment. Under no circumstances shall the medical equipment be used, operated by and person: a) under the age of 18, or b) while under the influence of intoxicants or narcotics; c) in an unsafe manner.

7. Renter shall demand, indemnify and hold harmless CFS Medical Supplies and Equipment, Inc. all of their agents, officers, servants, and employees from and against any all losses, liability claims damages, injuries, demands actions and causes of action whatsoever arising out of or related to any loss, damage or injury claimed by persons that may arise from the use, operations or driving of the medical equipment, provided that such loss or damage was not caused by the fault or gross negligence and willful misconduct of CFS Medical Supplies and Equipment, Inc or its employees. 

8. Renter assumes all cost and expenses of every kind and nature, including legal fees and disbursements arising out of and in connection with the use or operation of the medical equipment. 

9. CFS Medical Supplies and Equipment, Inc assumes no liability or responsibility for any acts or omissions of Renter or of Renter's agents, servants, or employees.

10. Renter shall notify CFS Medical Supplies and Equipment, Inc. Immediately of any and all accidents and damages resulting from the use or operation of the medical equipment.

11. Renter agrees to pay all costs, expenses, and attorney's fees incurred by CFS Medical Supplies and Equipment, Inc., in collecting sums due or in regaining possession of medical equipment or in enforcing or recovering any damage losses or claims against Renter.

12. Renter of the medical equipment shall in no event be deemed the agent or employee of CFS Medical Supplies and Equipment, Inc. in any manner or for any purpose whatsoever.

13. Any individual executing this Agreement as Renter in a representative capacity shall be bound personally, jointly and severally, with such fiduciary, corporation or other entity as to all obligations, expressed of implied, arising hereunder.

14. This Agreement shall be binding upon the distributes, heirs, and next of kin, executors, administrator and personal representatives of the undersigned Renter. 

15. We reserve the right t refuse renting to anyone if deemed necessary due to various reasons.

 

*** CREDIT CARD***

I authorize CFS Medical Supplies and Equipment, Inc., to charge the credit card in this authorization form according to the terms outlined above. This payment authorization is for the goods and services described above, for the amount indicated above only. 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, so long as the transaction corresponds to the terms indicated in this form.

 

***CLEANING FEE***

IF RENTAL IS RETURNED WITH HAIR, DIRT, MUD, SAND, STICKY SUBSTANCES, GUM, LEAVES, ODORS, THAT CAN NOT BE REMOVED FROM PRODUCT IE: URINE, FECES, SMOKE OR ANY OTHER SUBSTANCES WILL RESULT IN A $30.00 CLEANING FEE.

 

***EQUIPMENT REPLACEMENT COST***

HOSPITAL BEDS $1500.00

OBT-OVER BED TABLE $200.00

MATTRESS FOAM STD $250.00

PATIENT LIFT $900.00

TRAPEZE FREE STD $500.00

KNEE WALKER/SCOOTER $350.00

SCOOTER/POV $ 1200.00

TRANSPORT CHAIR $ 300.00

WHEELCHAIR 16", 18" $350.00

WHEELCHAIR 20", 22" PLUS $500.00

ELEVATING LEG REST $100.00

RAMPS 5FT $450.00

RAMPS 6FT $550.00

COOL THERAPY UNITS RX REQUIRED $ 400.00

NEGATIVE PRESSURE WOUND PUMP RX REQUIRED $3000.00

CPM MACHINE  $2000.00

MASSAGE TABLE  $600.00

IV POLE $150.00

POC-PORTABLE OXYGEN TANK $3000.00