Rental Form

Rental Agreement

(part one)

Equipment is hereby rented by the customer noted below from Medtech Services Inc., at the rates listed our Equipment Rental Prices sheet. Prices may be obtained by customers by calling Medtech Services. Such equipment will remain on rent until returned to Medtech Services, Inc., or upon notification from customer of the desire to purchase.

Equipment rented remains the property of Medtech Services, Inc

Customer may purchase rental equipment at Medtech prices.

Rental equipment is received in good condition and customer agrees to notify Medtech Services, Inc. promptly if maintenance or service becomes necessary.

Medtech Services will require a service charge for after hours or weekend calls for service, pickups, or deliveries requested by the customer.

All rental charges, transportation charges on shipments to and from out-of-town customers, special service charges and any other charges to be paid by the customer are due upon delivery. If payments are not in accordance with the terms and conditions of this invoice, Medtech Services Inc. may take possession of such equipment without notice.

Medtech Services Inc will not be responsible for any injury or damage resulting from the use of this equipment.

Customer will be responsible for any loss or damage to rental equipment from fire, theft, carelessness, or any cause other than reasonable wear.

Customer will not move any equipment without permission from Medtech Services, Inc.

We strive to give efficient, friendly service. Please contact us with any questions, concerns or problems.

Thank you

_______________________________________________ ____________
Customer Name and Signature Date

 

Fax Equipment Rental Form

(part two)

Personal Information

Name: _________________________________________
Address: _________________________________________
City, State, Zip: _________________________________________
Phone: _________________________________________
Phone: _________________________________________
Email: _________________________________________
   
Visit Information  
Equipment Needed: Standard Wheelchair:
Mobility Scooter:
Other: 		_______
_______
_______
_______
_______
Date of Visit: _________________________________________
Hotel where you will be staying: _________________________________________
Circle method of payment: Cash  Credit Card  Check
Credit Card Number: _________________________________________
Expiration Date: _________________________________________
Signature: _________________________________________

After you have completed the form, fax it to Medtech Services at (775) 826-6040. We will call or e-mail to confirm equipment availability for the date(s) you require the equipment. If you do not have access to a fax machine, you can either cut and paste the form into an e-mail message and respond within the message, call with the information, or mail the form to our physical address at:

Medtech Services, Inc.
555 Gentry Way
Reno, NV 89502