Rental Agreement

Fields with an Asterisk (*) Are Required

Equipment Description

Price Before Tax

Order # (Provided by Staff). Leave blank if unknown.

First name

Last name

User Weight

User Height

Patient Sex

Delivery/Pickup Date

Pickup Or Delivery

Pickup From Our Tampa Location

Pickup From Our Largo Location

Delivery (Additional Charges May Apply)

Phone

I previously provided my address and billing address on a Rental Request Form. (You may leave the address(es) blank below.)

Address 1

Address 2

City

State

Zip

Billing Address is the Same as the Delivery Address

Billing Phone

Billing First Name

Billing Last Name

Billing Address 1

Billing Address 2

Billing City

Billing State

Billing Zip

Will the Equipment be used on rough terrain or in soft sand?

Is this the first time renting this type of equipment?

Are you renting this equipment as a result of a fall?

Please Upload Your Identification (If not previously provided)

Please provide any additional information (Optional)

I agree to the Terms and Conditions & the Rental & Sales Agreement:

https://www.healthaidcompany.com/termsandconditions

https://www.healthaidcompany.com/rentalsalesagreement

I have received the Privacy Policy: https://www.healthaidcompany.com/privacypolicy

I have been provided Instructional Material:

https://www.healthaidcompany.com/patienteducation

I authorize Health Aid Company, Inc. to automatically charge the credit card on file, per the Rental & Sales Agreement.

Signature

Today's Date

Rental Agreement

Fields with an Asterisk (*) Are Required

Store Locations and Contact Information

Health Aid Medical - Tampa

Health Aid Medical - Largo