DESKTOP UNIT Rental - Weekly with Free Ground Shipping | Vitrectomy Recovery

Rental Periods *

Select rental period...

Patient's Name *

Surgery Date (First Rental Use Day | Equipment will deliver 1-2 days before this) *

Insurance Forms to File for Reimbursement *

-- Please Select --Yes, E0636 MutliPositional Patient Support System +$1.00No, thank you. I am not filing for insurance reimbursement

Physician Name / Practice Name / Address

Physician Phone

Damage Protection: Shipping Insurance, Covers damage over the $100 insurance included by FedEx, Protect Your Security Deposit from Possible Damage to Rentals During Shipping *

-- Please Select --Yes, please add insurance +$5.99No thank you, I will pay for carrier damages if damages occur on the return shipment

Is someone helping you with this order?

-- Please Select --No Allison John

How did you find us?

-- Please Select --Brochure from my Doctor Google Referral from a friend or colleague I am already a customer

Fuel Surcharge and FedEx Handling *

-- Please Select --Deliver to Residence, Indirect Signature Required +$15.00Deliver to Business, Adult Signature Required +$15.00Customer Pickup, FedEx Return +$7.50Customer Pickup and Return

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