1107 French Settlement Road, Kemptville, ON, K0G 1J0 (613) 258-9611

Equipment Lending

ONLINE Equipment Rental Request Form

BORROWER'S INFORMATION

Individual who will use the equipment

EMERGENCY CONTACT

OTHER INFORMATION

I hereby acknowledge that I relinquish BDH from liability should an incident occur, for the loan of the assistive device that is now recognized under my name. I understand that it is my responsibility to contact qualified medical personnel for instruction on the use and adjustment of the device. I agree to return the equipment to BDH clean and in its original condition, with report of any damage. I agree to return the assistive device to BDH.

Any equipment returned not cleaned the borrower will pay a fine equal to the value of the equipment.