Rental Request Form

Personal Information

* - Indicates required field

First Name*

Last Name*

Address*

City*

Province or State

Postal Code

Phone*

Email*

Any technical issue or malfunction of the rental equipment has to be reported to Aspirus Health At Home by the renter or his/her representative ASAP.
The renter is responsible for any damage or loss of the rental equipment and gives the right to Aspirus Health At Home to charge the cost of repair or the whole retail price of the equipment in case of loss.
The rental equipment has to be used in the proper way by the renter only. The renter will not allow the equipment to be used or played with by the others, especially children.
The rental equipment has to be kept in a dry and clean place when not in use.
The rental mobility products should not be used under the rain, snow or on icy or slippery surfaces.
The client is responsible for any injury or damage caused by negligence, misuse, accident or abuse of the equipment.
The renter hereby gives authorization to charge the on-file credit card for any due rental charge, repair cost of damaged equipment or the total cost for lost equipment.
The late payment interest charge will be 2% per month.