Rental Form

* = Required

Personal Information

Have you rented this equipment before?

Yes No

Name

Company

Home Address

Home Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Alternate Phone

Date of Birth

Patients Height

Patients Weight

Rental Information

Dates
From:
To:
Product
Do you have a specific purpose for this rental

Name of Resort or Hotel or Vacation Company

Street address of Resort or Hotel or Vacation Company

Exact Delivery Address for Equipment

Name of person the room reservation is under

Check in Date:

Check out Date:

Can we leave the equipment at the front desk?

Yes No

Is the front desk on the same property as the unit?

Yes No

What floor is the unit on?

First Second Third Higher than Third

Are there stairs or an elevator? Stairs Elevator

Is there a code for the gate or door you can provide for access?

Yes No

Please provide any applicable codes

Rental Terms and Conditions:

Completion of this form does not guarantee availability.
Please note that times will be treated as requests. We cannot make special time accommodations for deliveries or pickups on Saturdays. Any special requests will need to be made between you and your destination. If you must have a piece of equipment upon arrival, you will need to get permission from your destination and provide us with the details.

We do have a cancellation policy available at
http://www.burkespharmacy.com/dme-#rentals

Once a delivery is made we do not offer refunds of any amount.

People renting a "Beach Wheelchair" should be aware these chairs have a seat height of 31" from the ground. We only delivery BWC's to the beach access that will be used as the "BWC" is not for use on hard or rocky surfaces.

SHIPPING & DELIVERY POLICY

Burke's Main Street Pharmacy's shipping & delivery policy is as follows:

On-Island Deliveries:
$3 for pharmacy, $10 for medical equipment

Off-Island Deliveries:
$3 for pharmacy, $20 for medical equipment in service area

Outside of service area:
Special Rate

Choosing yes below acknowledges and agrees to all of the above statements and conditions. Agree

Please provide any comments, requests or questions

Please type your full name to serve as a signature that the above information is true and accurate.

Rental Form

Personal Information

Rental Information

Dates

Rental Terms and Conditions:

SHIPPING & DELIVERY POLICY