Equipment Rental Agreement

For Löwenstein Luisa/CARO/Prisma VENT/BiLevel devices

Who is renting the device?

Patient Name for invoice

First Name

Last Name

NDIS Client Number (if applicable)

NDIS Plan Dates (if applicable)

NDIS Client's Date of Birth (if applicable)

Day

Month

Year

Contact Name for Client Communication

Shipping Address (For Rental Device)

Contact Phone Number

Contact Email

Desired Rental start date

Rental length

Rental Device

Patient Interface

PO Number or reference for invoice (optional)

Contact name for invoices

Accounts phone number

Accounts email

Comments (optional)

Prescription upload (optional)

GENERAL RENTAL TERMS & CONDITIONS

It is important that you read and understand the following information relating to the rental of this equipment.

All equipment remains the property of LMWA. On the expiry of the agreed rental period if the nominated equipment is not purchased, returned to LMWA, or a further rental period negotiated in writing, LMWA maintains the authority to pursue by any means necessary the return of the said equipment in the same condition as initially rented.
LMWA will claim the value of any equipment lost, damaged or stolen from the renter whilst in the care of the renter.
The total rental cost must be paid upfront. Devices returned more than 2 days after the end of the rental period may incur an additional rental charge of 1 month.
If there is a default in payment or failure to return the equipment, LMWA will include the cost of unreturned equipment as well as outstanding rentals in a claim for recovery of debt. This includes bank, collection agency, and account-keeping fees in addition to any outstanding amounts.
LMWA warrants that all rental equipment be maintained as per the manufacturer's specifications, at the commencement of the rental period and requires that rental equipment be returned in the same condition on the expiry of the rental agreement. Whilst due care is taken to ensure that all equipment is serviced in accordance with the manufacturer's specifications, the renter must advise LMWA immediately of any equipment malfunction.
A refundable security bond for all rental equipment is required. This security bond is not a payment of rent in advance. In the event of a default of payments or damage to the device, LMWA reserves the right to offset the value of the security bond against any outstanding amount. This includes any bank, collection agency, and account-keeping fees in the pursuit of any outstanding payments. The security bond will only be refunded in full if all rental equipment is returned in the condition that the equipment was provided.
- Please ensure all accessories are returned including: carry bag, equipment manuals, power cord and device.
Except where specified, rentals are for a calendar month and will be charged in advance.
- An invoice will automatically be sent at the end of each 30 day period for payment for the next 30 days.
- Consumables will be shipped when the invoice is sent to the Accounts contact.
- If you wish to cancel your rental - contact the LMWA team 1 week before the end of the month.

By signing and submitting this agreement, I confirm that:
- this device will only be used under the advice and oversight of a medical practitioner
- that I have read and agree with the 'terms and conditions

Signature

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