Rental Form for AABA Family Medical

Your Name: 

Your Age: 

Your Height: 

Your Weight: 

Please make your selection from the following list...

 Bath Bench    Beach Transport    Commode    Crutches    Hip Chair   

 Hospital Bed Electric    Hoyer Lift    Knee Walker    Lift Chair    Nebulizer   

 Over Bed Table    Power Chair    Ramps    Rollator    Stair Lift   

 Transfer Bench    Rolling Walker    Wheelchair    Transport Chair    Scooter   

Billing Name: 

Home Address: 

City:   State:   Zip Code: 

Home Phone:   Cell Phone: 

Delivery Address: 

City:    State:   Zip Code: 

Your E Mail Address: 

Please type request for items not listed above or any other comment you may have!
Close Window

Refunds will not be made for any unused portion of the rental period. A non refundable deposit of $50.00

is required at the time of reservation, and the balance is due in full on the day of delivery. The customer must have a valid credit card and ID at the time of reservation. All equipment must be returned in the same condition as it was provided. The customer agrees to safeguard the equipment and is responsible for any damages or theft. Furthermore, the customer agrees to reimburse AABA Family Medical Supply for any loss or damages to any and all rented equipment with the exception of normal wear.

AABA Family Medical Supply, its employees and or agents, make or have no representations as to the proper use of the equipment, its therapeutic value or purpose, any use to which it may be put or the length of time such equipment shall be used. The undersigned customer/patient or his/her designated reprehensive, hereby exonerates AABA Family Medical Supply, its employees and or agents of and from any and all injuries and or damages resulting from the use of the aforementioned, and agrees to save and hold them harmless there from.