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Baby Scale Rentals...anywhere in the continental USA!  Simply fill in the information on this form, print it out,  and fax the signed copy to 877-909-7867 or mail form to:   Lactation Connection, PO Box 265, Bluff Dale, TX 76433.  Questions?  Call 800-216-8151. 

Name:  Last, First & Spouse: 

Street Address:   

City:    State:    Zip: 

Drivers License State:          Number: 

Social Security Number:    

Email address:        

Credit Card #:              Expiration Date:                CVV Code: 

telephone#           work/mobile#

Check the applicable boxes below.   Your order will be processed without tax if you are outside Texas.  Texas residents add 6.75%.   $25 shipping will be added to all orders for rentals.  This will cover Fedex ground shipping as well a return label for return shipping that will be emailed upon your request.  (Terms of rentals will begin up to 5 days after ship date to allow for rental to arrive.  Returns are considered on-time if scanned by FedEx on or before the date due.)  Baby Scale weighs in 1/2 oz increments.

Select Applicable Items:   one mo scale rental   $35    three mo scale rental  $90   

add additional  $25 for 2-3 Day Premium Shipping

By signing below, I agree that the information provided is true and accurate and that I accept responsibility for the whereabouts of the equipment rented as well as the charges to my credit card for the initial rental and $35 per month thereafter. I understand that this is a contract for the full term of the rental and that no refunds will be given for early return.  I further understand that I will be charged a $5 cleaning fee if scale is not clean upon return.

Signature of lessee/cardholder:  

 

NOTE:  If you do not wish to mail or fax, you can scan and email your form.  Please call 800-216-8151 for email address.

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