Durable Medical Equipment

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Acknowledgement*

by checking this box I have read the acknowledgement below:

I hereby acknowledge receipt of the following item(s) of medical equipment loaned to me by Senior Resource Association for the applicant’s sole use and that this equipment will not be loaned to anyone else. I acknowledge that this equipment will be used as it is designed to be used and that I will exercise ordinary and reasonable care thereof.

Select all durable medical equipment received:*

Wheelchair
Bedside Commode
Rolling Walker
Portable Ramp
Walking Cane
Shower Chair
Transfer Bench
Adult Briefs
Other

List other items received:

Describe the condition of the equipment:

Condition of equipment*

I have examined the equipment and that I find it in good condition and fit for its intended use.

Future borrowers

In consideration of future borrowers, I promise to clean and sanitize the equipment prior to returning it.

Name*

First Last

By typing your name into this box you: I understand that this loaned equipment remains the property of the Senior Resource Association and is available to me at no cost. I hereby forever release and discharge Senior Resource Association and its employees or agents from all liability, claims, demands, and actions that I may have for any injury to my person or my property that results from my use of the loaned equipment and therefore they will not be held responsible for any defect in the equipment or any accident or injury that may occur during or subsequent to the use of the equipment. I hereby waive any and all claims I may have against the aforesaid related to the use of the equipment.

Date

Serving Our Community

Promoting health, happiness, and independence.

Durable Medical Equipment

Senior resource Association recycles gently used medical equipment and redistributes items to those who need it most.

Frequently Requested Equipment:

WHEELS CHAIRS

BEDSIDE COMMODES

ROLLING WALKERS

PORTABLE RAMPS

WALKING CANES

SHOWER CHAIRS

TRANSFER BENCHES