Rental Information

Patient Name(Required)
(if different from above)
Address
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Date of Birth

Rental Medical Equipment Information

Rental Period Start Date:
Rental Period End Date:

Rental Requirements:

Renter Must Be A Major Credit Card Holder And Provide Credit Card Information, As Well As Sign The Whitesell Home Medical Equipment Rental Agreement
I understand and accept the following terms:
  1. I understand that there will be no finance charges. This plan is a courtesy to our patients and, in order for this to continue, we must have and accept timely payments.
  2. I authorize Whitesell Home Medical Supply to charge my credit card the stated rental amount and frequency as stated above.
  3. I understand these charges are due directly to Whitesell Home Medical Supply.
  4. I understand that the failure to return the rented medical equipment stated above by the agreed-upon return date may result in a charge to my credit card for the full retail amount stated above.
  5. I understand that if payment is not made on these terms, Whitesell Home Medical Supply may forward this account to collections and pursue legal actions, if necessary.
  6. I agree to pay all costs of collections, including court costs and attorney fees for all delinquent balances.

Rental Agreement

Please read completely before signing:
  1. Renter has inspected the medical equipment and confirms that it is in good condition. The Renter shall return the equipment in the same condition it which it was received.
  2. I authorize Whitesell Home Medical Supply to charge my credit card for the initial rental fee amount. I then understand that I will receive a monthly statement for any subsequent rental fee charges.
  3. Renter has been instructed how to use the equipment by a Whitesell Home Medical Supply employee.
  4. Whitesell Home Medical Supply may repossess the equipment being rented without demand at any time if it is being used in violation per terms of this agreement.
  5. Medical equipment being rented is due back to Whitesell Home Medical Supply by 4:30 Monday- Friday or on the previously agreed upon date in the Medical Equipment section above.
  6. The Renter assumes all risk of liability for any loss, damage or injury, including death, to the person or property of the Renter or others arising out of the use and operation of the medical equipment during the rental period.
  7. The Renter acknowledges the following restrictions apply to the rented equipment at all times. Under no circumstances shall the medical equipment be used or operated by someone (1) under the age of 18 without adult supervision, or (2) under the influence of intoxicants, narcotics or illegal substances or (3) in an unsafe manner.
  8. The Renter is fully responsible for the medical equipment during the rental period and will compensate Whitesell Home Medical Supply for the full costs of any repairs for any damage or full cost of replacement for extensive damage, loss, theft, destruction of or failure to return the medical equipment during the rental period. The Renter understands and authorizes Whitesell Home Medical Supply to charge the credit card provided by the renter for any such repairs or replacement costs.
  9. The Renter understands that every attempt will be made by Whitesell Home Medical Supply employees to make contact with Renter, using the information provided above, regarding any credit card charges that will be made pertaining to payment for extensive damage, loss, theft, destruction of or failure to return the medical equipment during the rental period.
  10. The Renter agrees to provide all costs for attorney and solicitor-client fees incurred by Whitesell Home Medical Supply in collecting sums due or in regaining possession of the medical equipment or in enforcing any damage, losses or claims against the Renter.
  11. The Renter understands that we, as Whitesell Home Medical Supply, our agents or assignees may call by telephone regarding your rental agreement. The Renter agrees that we, our agents or assignees may place such calls using an automatic dialing/announcing device. The Renter agrees that we, our agents or assignees, may make such calls to any telephone number provided including any mobile telephone or similar device. The Renter agrees that we, our agents or assignees may, for training purpose or to evaluate the quality of service, may listen to and record phone conversation had with us and/or agents or assignees.
  12. The Renter assumes all costs, including legal fees, in connection with the use or operation of the medical equipment during the rental period.
  13. The Renter shall notify Whitesell Home Medical Supply immediately of any and all accidents and damage resulting from the user operation of the medial equipment.
  14. Whitesell Home Medical Supply assumes no liability or responsibility for any acts or omission of the Renter.
  15. The Renter Shall in no event be deemed the agent or employee of Whitesell Home Medical Supply in any manner at any time.
  16. This agreement is binding upon the heirs, next of kin, executors, administrators and personal representatives of Renter.
  17. The Renter shall not permanently remove the equipment from the address of the Renter or the Location indicated above without prior written approval from Whitesell Home Medical Supply. The Medical Equipment Rental is intended to make activities of daily easier for Renter. The Renter Shall inform Whitesell Home Medical Supply upon demand of the exact location of the equipment while it is in the Renter's Possession.
  18. No Allowance will be made for any rented equipment or portion thereof which is deemed not to have been used. Acceptance of the returned equipment by Whitesell Home Medical Supply does not constitute a waiver of the rights of Whitesell Home Medical Supply has under the Rental Agreement.
  19. The Renter shall not pledge to encumber the rented equipment in any way. Whitesell Home Medical Supply may terminate this Agreement immediately upon failure of Renter to make rental payments when due, or upon Renter's filling for protection from creditors in any court competent jurisdiction.
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