Equipment Lending

BORROWER'S INFORMATION Full Name * Individual who will use the equipment Street Address * City * Province * Postal Code * Phone 1 * Phone 2 Email Address * Date of Birth * Health Card Number * Version Code * Preferred Language * English French EMERGENCY CONTACT Full Name * Relationship to Borrower * Street Address * City * Province * Postal Code * Phone 1 * Phone 2 Email Address * OTHER INFORMATION Equipment Requested * Transfer Wheelchairs 4 Wheel Walkers 2 Wheel Walkers Walkers (no wheels) Canes Crutches Bed Helper Rail Bath Transfer seats (also known as shower benches) Commodes including over the toilet commodes Equipment Rented Transfer Wheelchairs 4 Wheel Walkers 2 Wheel Walkers Walkers (no wheels) Canes Crutches Bed Helper Rail Raised Toilet Seats Bath Transfer seats (also known as shower benches) Commodes including over the toilet commodes Reason for equipment use: * How did you hear about us? * 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. Yes No I would like to receive email updates from Beth Donovan Hospice. * Yes No Submit Last Name

Equipment Lending

ONLINE Equipment Rental Request Form

BORROWER'S INFORMATION

EMERGENCY CONTACT

OTHER INFORMATION

Client Referral Form

Referral Information

Client Information