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Equipment Lending

ONLINE Equipment Rental Request Form

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NOTE:

Equipment Request for Surgeries - equipment can only be requested at the earliest two weeks before surgery date. We do not have enough equipment to request holds longer than two weeks from the actual date of surgery. Thank you.

This Agreement is made on *

between BETH DONOVAN HOSPICE (“BDH”) and the BORROWER

BORROWER'S INFORMATION

Full Name *

Individual who will use the equipment

Street Address *

City *

Province *

Postal Code *

Home Phone *

Cell Phone

Email Address

Date of Birth *

Health Card Number *

Version Code *

Preferred Language *

English

French

EMERGENCY CONTACT

Full Name *

Relationship to Borrower *

Street Address *

City *

Province *

Postal Code *

Home Phone *

Cell Phone

Email Address *

OTHER INFORMATION

Equipment Requested *

Transfer Wheelchairs

4 Wheel Walkers

2 Wheel Walkers

Walkers (no wheels)

Canes

Crutches

Bed Helper Rail

Bath Transfer seats (also known as shower benches)

Commodes including over the toilet commodes

Equipment Rented

Transfer Wheelchairs

4 Wheel Walkers

2 Wheel Walkers

Walkers (no wheels)

Canes

Crutches

Bed Helper Rail

Raised Toilet Seats

Bath Transfer seats (also known as shower benches)

Commodes including over the toilet commodes

Reason for equipment use: *

NOTE: CREDIT CARD INFORMATION

Beth Donovan Hospice will be collecting credit card information before equipment is lent out, for the purpose of ensuring the equipment is returned on time and in good clean condition.

How did you hear about us? *

Pickup Date *

Return Date *

I hereby acknowledge that I relinquish BDH from liability should an incident occur, for the loan of the assistive device that is now recognized under my name. I understand that it is my responsibility to contact qualified medical personnel for instruction on the use and adjustment of the device. I agree to return the equipment to BDH clean and in its original condition, with report of any damage. I agree to return the assistive device to BDH.

Any equipment returned dirty or damaged, the borrower will pay a fine of $50.00 per item.
Any equipment NOT returned after the 3-month loan period, the borrower will pay $40.00 per item per month.

Yes

I would like to receive email updates from Beth Donovan Hospice. *

Yes