Portable Oxygen

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Used
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RENTAL FACT SHEET
Make your reservation now, it's free and you can cancel or change your reservation anytime before we ship your POC without being charged or penalized in any way.
CUSTOMER INFORMATION
First Name:
Middle Name:
Last Name:
Home Phone:
Cell Phone:
Email:
POINT OF CONTACT (if other than customer)
Name:
Phone:
Relationship to patient
Email:
SHIP TO ADDRESS
Address:
Unit #:
City:
State: Zip:
Contact phone at this address:
PICK-UP ADDRESS (if different from ship to address)
Address:
Unit #:
City:
State: Zip
Contact phone at this address:
CHOOSE THE SYSTEM(S) YOU WOULD LIKE TO RENT




Other, please specify:

CHOOSE THE NUMBER OF BATTERIES YOU WILL NEED
EXPECTED USE
RENTAL DATES
Liberty Medical allows patients to receive equipment up to 3 business days prior to the first travel day at no additional charge.
What date would you like to have the equipment arrive?
What is your first travel day? (rental start date)
What is your last travel day? (rental end date)
On what date would you like the equipment picked-up for return to Liberty Medical?
Comments: