Liberty Medical - Portable Medical Oxygen - Airline Oxygen

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
Inogen One Eclipse II EverGo Other, please specify:
CHOOSE THE ACCESSORIES YOU WILL NEED
International power cord (adapter) Accessory bag Desktop charger
CHOOSE THE NUMBER OF BATTERIES YOU WILL NEED
1 2 3 4 Other: Note: two batteries are automatically supplied with each rental. Additional batteries MAY have additional fees.
EXPECTED USE
on aircraft 24 hrs/day 8 hr sleeping As needed Flow (liter/min):
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:
Click the Submit button below and we will call you back to confirm the data and to coordinate payment. Thank you for your order!


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