Delivery & Pickup Ticket

Delivery or Pickup
DeliveryPickup
Rented

Customer Information

Customer Name:

Email:

Phone:

Customer Address 1:

Address 2:

City/State/Zip:

Account Number:

DOB:

Height:

Weight:

Product Information

Type
BedPowerchairLift chairScooter

Model:

Serial #:

Description:

Comments/Instructions:

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. I authorize payment of medical benefit to the undersigned supplier of services described. In the event of any loss or damage to the above-mentioned Medical Equipment will become the financial responsibility of the undersigned. The undersigned has been properly instructed about the safe operating procedures for this Medical Equipment. The undersigned further agrees not to alter the equipment in any way, agrees that the Medical Equipement is for in home use only and agrees to hold harmless American Medical Equipment Supplies and Repairs, LLC, and its representatives, for any injuries or damages that may result from use of this Medical Equipment.

Receiver's Name:

Requested Delivery Date: