PEAKS & PLAINS, INC.

___ 13524 E. Sprague, Spokane Valley, WA 509-927-0991

___ 9996 N. Newport Hwy. Spokane, WA 509-484-0903

www.peaks-plains.com

NAME: ______DATE: ______

ADDRESS: ______

CITY: ______STATE: ______ZIP: ______

PHONE: ______CELL PHONE: ______

HEIGHT: ______WEIGHT: ______OF CLIENT USING ITEM.

LOCATION OF EQUIPMENT: ______

VALID ID USED: (I.E. DRIVER’S LICENSE #) ______

ü  / Item Being Rented / Type of item / Monthly Rental Fee / Deposit
Lift Chair / $150.00 / $139.00
Scooter – No insurance rentals / GB 106 Buzzaround / $120.00 weekly / $100.00
Scooter – No insurance rentals / GC-222 Companion / $150.00 weekly / $100.00
Wheelchair / Standard / $50.00/ $35.00 weekly
Wheelchair / Lightweight / $50.00/$35.00 weekly
Wheelchair / Bariatric / $130.00/ $55.00 weekly
Knee Walker / $115.00mo/$40 weekly / $40.00
Transport Chair / $45.00/ $35 weekly
Hoyer Lift / $125.00 / $100.00
Electric Lift / $250.00 / $200.00
Hospital Bed / Semi-electric / $150.00
Hospital Bed / Fully Electric / $180.00 / $180.00
Walker w/out wheels / Standard / $25.00
Rollator / $40.00
Ramps / All Sizes / $50.00 / $50.00
Massage Table / Folding / $75.00 / $75.00

RENTAL DATES: FROM ______TO ______

ITEM #:______Item Description: ______SERIAL #______Tracking ID# ______

PAYMENT TYPE: (circle one) CASH CHARGE (Pay Everywhere)
DATE DUE BACK (see terms on Due dates): ______

Please provide customer a copy of their signed agreement and the agreed return date.

TERMS OF RENTAL

1)  Renter agrees to pay for rental in accordance with the terms listed above and will be liable for additional rental payments in accordance with store rental policy if the rental item is not returned on the date indicated above. Renter agrees to leave a deposit method for any charges occurred for late fees or damaged equipment. Deposit will be made by putting a credit card on file.

2)  Renter agrees to return the unit in the same condition as when it was rented except what would be considered normal wear and tear. The cost of any repair or clean-up of the unit will be deducted from renters deposit and/or due at the time of return.

(a)  LIFT CHAIRS: Any damage outside of normal wear and tear (i.e. stains, tears, electrical damage, broken frame) will incur a $400.00 fee.

3)  Renter assumes all liability for the proper use of the chair and holds Peaks and Plains Medical or associated companies harmless from any unsafe use of the item by renter.

4)  Renter understands that the rental item is for the express single use of the patient or resident for whom it is rented and agrees that it may not be loaned or used by others.

5)  Renter agrees that he/she will be responsible for any costs to Peaks and Plains Medical may incur in collecting past due amounts owed for rental of this unit.

6)  Renter understands there will be no proration for early rental returns, no in store credits or cash back.

7)  If you decide to purchase any rental equipment (if it is available for purchase), the amount of your rental does not go towards the purchase and any rental amounts incurred must be paid in full prior to the purchase of the equipment.

8)  All rentals are due back on the date stated by 5:00 pm, at the store location it was rented. If it is not returned you will be billed for an additional month. This amount will not be refunded or credited. We will not pick up or deliver rental lift chairs on the weekends.

9)  To make changes on your rental you must call the store location designated above during business hours; Monday thru Friday 9 am - 5:30 pm. Rental changes must be made prior to the due date and time listed.

I have read and agree to be bound by all terms and condition listed above for the rental of the item(s) indicated.

Signed______

Date______Store Employee renting unit: ______

Equipment Rental Agreement 2015 ACHC Accredit. April 1, 2015